The document outlines plans for developing integrated care communities across South Cheshire and Vale Royal. Key points include: - The formation of 5 care community teams to provide coordinated, patient-centered care across the region. - Initial priority projects include developing the care community teams, improving GP out-of-hours care, and musculoskeletal physiotherapy. - Achievements so far include aligning staff to the 5 communities, implementing rapid response services, and beginning multidisciplinary team meetings. - Future goals involve strengthening primary care partnerships, expanding social care support, and using data to better manage patient risk levels.

1. Sharing
Sharing

2. Outline of the Day
House keeping – Fire/Toilets/Tea & Coffee / Lunch / Other Logistics
Format of the Day
•AM Presentations each of 20 minutes - Timekeeping / Questions
– 09:15/11:15
– 11:30/13:00
•PM Round Tables (Two choices from Four Tables)
– Patient centred care (Dr Andy Spooner / (F) Jon Develing )
– Integrated care (Denise Frodsham / (F) Tracy Cole)
– Social care integration (Natalie Park / (F) Charlotte Hall
– Person centred nursing associates (Louise Kitchner, Phil Hough / (F) Phil Meakin)
•Networking
•Exhibition Stands
Sponsors, help and support

3. Exhibition Stands Organisation
Population Health Cerner UK
Get It Right First Time (GIRFT) GIRFT - North West Hub
Model Hospital NHS Countess of Chester FT
Advancing Quality Alliance AQUA
Commissioning Support (CSU) NHS Midlands & Lancashire CSU
Participatory Budgeting Social Care
Signs of Safety Social Care
Healthy Wirral Local Partnerships
West Cheshire Way Local Partnerships
Connecting Care Local Partnerships
Caring Together Local Partnerships
Academic Health Science Network The Innovation Agency
Cheshire Career & Engagement hub DoHR and Health Education England
Continuing Health-Care (CHC) NHS Cheshire and Wirral CCGs CHC Team
Live Well – Cheshire East Local Authority
Information Sharing / Data Management Local Authority
Cheshire Care Record Cheshire

5. Presentation 1
Dr Liz Mear
Chief Executive
@MearLiz

6. AHSNs
• 15 Academic Health
Science Networks across
England
• Licensed and funded by
NHS England, NHSI and
Office for Life Sciences
• Promoting innovation in
healthcare
• Single structure to
improve outcomes
• Promoting economic
growth in regions and for
UKPLC

7. Our aims and objectives
• To spread innovation at pace
and scale across NHS
• Act as an agent of change by
creating collaborations
between higher education,
NHS, industry, third sector,
patients and public
• Secure investment and boost
the economy of the North West
Coast
• Improve equality of access to
innovation.

8. Presentation 1
30 Innovation Fellows – innovative health
technologies and services into action
National Innovation
Accelerator
Francis White spreading the use of
Kardia from AliveCor, the UK’s first
mobile heart monitor
Dr Lloyd Humphries
Patient Knows Best
Dr Penny Newman
Health Coaching

9. Presentation 1
Accessing the zero cost NHS Innovation
and Technology Tariff 2017-18
The Innovation and Technology Tariff (ITT):
•Incentivises the adoption and spread of transformational
innovations
•Removes the need for local multiple price negotiations
•Guarantees automatic reimbursement
•Allows NHS England to negotiate ‘bulk buys’
•Six themes in pathfinder year

10. Web-based applications for the self
management of chronic obstructive
pulmonary disease
Based on an average CCG with 5000 patient
with COPD and 25% reduction in exacerbations
and hospital admissions:
In year savings of >£200k
Cost £20 per patient
For each period of activity, providers must report
back on a minimal data set

11. Management of benign prostatic
hyperplasia as a day case
Alternative to transurethral resection of
prostate (80 min op under GA, 2-3 day LOS)
The UroLift system works by lifting and
holding the enlarged prostate tissue out of
the way, like opening curtains on a window,
to relieve the compression on the urethra.
No cutting, heating or removing of prostate
tissue.
(<30 min day case under local anaesthetic
or light sedation)

12. AHSN Network, Working to
reduce AF related strokes

13. Correct: Supporting spread of NICE approved
technology to improve pathways
• Improving the warfarin
pathway
• Patient Self-testing
• Digital integration to
support clinical teams
• Empowering and engaging
patients
• Primary care &
hospitals

15. NHS Eastern Cheshire CCG
Nursing Home Scheme
Dr Paul Bowen
GP, Chair,
NH Scheme clinical lead

16. Marmite for GPs

18. • 70% of people with dementia who are admitted to a nursing
home will die within first 6 months
• Nationally, < 50% die within their (nursing) home, most dying
in a hospital.
• In E Cheshire, in some homes, nearly 90% of residents died
within their preferred place of care.
• The national average rate of admissions for NH residents is 2.5
admissions per nursing home bed per year, in E Cheshire it is
less than 0.7.
• This represents a saving on admissions alone of £4.21m (E
Cheshire rate vs National rate)
• The NH scheme costs the CCG £300/per bed, per year = £293k
The facts

19. • There can be wide variations in A&E
attendance and unscheduled admission rates
for residents from different nursing homes.
This activity is influenced by three key factors:
– Resident-centred (scope and complexity of need)
– Establishment related
– System based factors, including the nature and
provision of primary care medical services.
Variation

20. • One GP, one practice, one home
• Regular, weekly proactive “rounds”
• Standardised approaches to care planning, incl rest of
life plans, medication review, MDT working,
communications, EOL plans, weighing, covert medication
etc
• Regular peer support (quarterly meetings)
• Staff and patient/family support and conversations
• Risk acceptance
• NH support – dietician, pharmacist, TVN, Geriatrician
The Scheme

22. • Focus on outcomes (CCG)
• Develop a self supporting culture
• Recruit the willing
• Consider but do not over-value GP choice
• Value the importance of continuity and
relationship building
• Consider the GP (and wider NHS team) as
part of the NH team (and vice versa)
• Evolve, adapt and review
• Learn to love marmite
Key Ingredients

24. Over diagnosis
Dr Andrew Spooner
How Person Centred Care unlocks
better, more efficient outcomes

25. My Journey

26. My Journey

27. Where did we arrive?
• Acute care > CDM
• Young sick patients > Patients older, more co morbidity
• 6% of GDP > Spending Increase
• Community delivered > Shift to specialist and hospital
• Waiting lists >Procedures of Limited Clinical Value
• Statins are post MI >Statin for all at 10% risk
• Patient driven consultations for a problem >
Population Medicine and Health Checks
• A discussion with limited options > Healthcare Factory

28. What is the problem?
• The health service is running out of money
• Services are always over busy
• Improvement in life expectancy is stalling
• Patients are unhappy
– (frail elderly and young with acute illness)
• Professionals cannot be recruited or leave the service
• Investment and change never seems to resolve the
problem
• Wrong person treated in the wrong place with the
wrong intervention

29. Person Centred Care
“ I can plan my care with
people who work together
to understand me and my
carer(s), allow me control,
and bring together services
to achieve the outcomes
important to me.”
(National Voices 2013)

30. Person Centred Care
• The public is less willing
to be controlled by
professionals
• Even the word patient
is contentious
• This is desired at all
ages but is most
pronounced in the frail
“ I can plan my care with people
who work together to understand
me and my carer(s), allow me
control, and bring together
services to achieve the outcomes
important to me.” (National Voices
2013)

31. Patient Example
• Gladys

32. Person Centred Care
• Warranted and unwarranted variation
• Control Systems and audits
• KPI
System Controls in Action
• Was a cancer referred for diagnosis
• If there is a crisis it will go to casualty and be a
late diagnosis
• The MDT apparently can’t not treat so cant be
diagnosed as non emergency
• Patient likely to die within a year if late stage
presentation

33. STP plan
• Much detail
• Overarching themes
• Treatment and referral rules
• Variation is reduced
• Services and clinicians have clinical audits
• 100% compliance is the aim
• Existing guidance and methods produce
improvement
• Early diagnosis and treatment leads to lower cost

34. STP Plan implications
• Switch from decisions by GPs about when to use
the system to selection by secondary care
• Reduction in variation, warranted and
unwarranted
• Flexibility for individuals is lost
• It replaces person centred care with disease
centred care
• All the existing variation to keep people away
from services and individualise is lost
• Maybe that would be a price worth paying

35. Choosing Wisely / Overdiagnosis
Goldilocks Care
• Investigation
• Diagnosis
• Referral
• Treatment

36. DIAGNOSTIC TESTS
How well do we understand statisitics?
• Prevalence is 1 in a 1,000 patients
• Test identifies correctly everyone who truly
has the disease and has a small false
positive rate of 5 percent
• What is the chance that a person found to
have a positive result actually has the
disease – expressed a percentage?

37. Positive
Negative
Test
Disease
Present Absent
10001
1
0
999
50
949
1:50 2%
Test specificity
Prevalence in this population
1:1000
False Positive rate 5%
For 1000 Patients (rounded)

38. Date of download: 8/31/2017
Copyright © 2014 American Medical
Association. All rights reserved.
From: Medicine’s Uncomfortable Relationship With MathCalculating Positive Predictive Value
JAMA Intern Med. 2014;174(6):991-993. doi:10.1001/jamainternmed.2014.1059
Distribution of Responses to Survey Question Provided in the Article TextOf 61 respondents, 14 provided the correct answer of 2%.
The most common answer was 95%, provided by 27 of 61 respondents. The median answer was 66%, which is 33 times larger than
the true answer.
Figure Legend:

39. Challenging Conventional
Thinking
• Early diagnosis reduces long term costs
• Secondary care is a good place to write system rules
• If a treatment works to improve care of the disease it
must improve care overall
• Improving a biochemical parameter always improves
outcomes
• Side effects are small and easily controlled
• Patients want early treatment
• All patients want the same thing
• Patients want to take a tablet for low risk illnesses
• Patients always want more treatment

40. Unlocking Warranted Variation
• We have removed interventions that always harm
• The effect of an acute admission on individuals is
different
• This happens correctly now but is being lost
• Person centred care is the route to unlocking the
savings of overdiagnosis of individuals
• The savings are currently large and could be much
bigger
• The current audit and control systems do not
demonstrate the effectiveness of person centred care

41. FIVE QUESTIONS TO ASK MY DOCTOR OR
NURSE TO MAKE BETTER DECISIONS TOGETHER
Do I really need this test, treatment or
procedure?
What are the risks or downsides?
What are the possible side effects?
Are there simpler, safer options?
What will happen if I do nothing?
• Guideline Front sheet
• New Forms
• Multimorbidity Guideline

43. South and Vale Royal Community
Services
Denise Frodsham & Karen Moore

44. A new collaboration formed October 2016 between
•Mid Cheshire Hospitals NHS Foundation Trust (MCHFT).
•Cheshire and Wirral Partnership NHS Foundation Trust (CWP).
•South Cheshire and Vale Royal GP alliances.
•Hosted by MCHFT but being developed as unique brand CCICP
Formation of the PartnershipFormation of the Partnership

45. To transform, develop and deliver
health care services in the community
that are focused on delivering high
quality, person centred care.
Partnership AimPartnership Aim

46. • I will be more in control and more in charge of my own
health
• I will live in a community with facilities and functions that
promotes my health and wellbeing
• I will feel that my family, friends and community are my
'first care team'
• I will experience care that works towards my individual
goals and ambitions, and care that looks at me as a whole
person and not a disease or body part
Vision for the Population ServedVision for the Population Served

47. 1. Care Community Team
development
2. GP Out of Hours
3. Musculoskeletal Physiotherapy
Underpinned by enabling work streams of IT, Estates and
Clinical Priority projects agreed for 2017/18Clinical Priority projects agreed for 2017/18

48. Care Communities (Home First
Project)
Care Communities (Home First
Project)Project Objective:
To support the development of five Care Community teams across the South
Cheshire and Vale Royal (300,000 population). The aim is that all care will be
managed, co-ordinated and flexibly centred around the patients needs.
Offering a high quality standardised service but tailored to the priorities and
needs of the local population.
Project Objective:
To support the development of five Care Community teams across the South
Cheshire and Vale Royal (300,000 population). The aim is that all care will be
managed, co-ordinated and flexibly centred around the patients needs.
Offering a high quality standardised service but tailored to the priorities and
needs of the local population.
Each Care Community Team will:
•Have rapid, unplanned and planned multidisciplinary functions.
•Be supported by a single senior Manager
•Consist of:
Community Nurses, Physiotherapists,
Occupational therapists, Speech and language therapists,
Care facilitators, MSK physiotherapists,
Advanced Community Practitioners.
Podiatrists
•Supported by specialist teams ‘invited in’ e.g. respiratory, tissue viability
diabetes, etc
Each Care Community Team will:
•Have rapid, unplanned and planned multidisciplinary functions.
•Be supported by a single senior Manager
•Consist of:
Community Nurses, Physiotherapists,
Occupational therapists, Speech and language therapists,
Care facilitators, MSK physiotherapists,
Advanced Community Practitioners.
Podiatrists
•Supported by specialist teams ‘invited in’ e.g. respiratory, tissue viability
diabetes, etc

49. - Staff have been aligned to 5 Care Communities.
- Management structure has been redesigned with staff
consultations and recruitment completed.
- IT strategy and business case to support fit for purpose
mobile workforce has been developed and investment
agreed. Implementation programme complete by Sept
18. Staff engagement sessions being progressed
- Organisational development strategy has been
developed with sessions on “preparing for change” set
up for Nov 17.
- Staff have been aligned to 5 Care Communities.
- Management structure has been redesigned with staff
consultations and recruitment completed.
- IT strategy and business case to support fit for purpose
mobile workforce has been developed and investment
agreed. Implementation programme complete by Sept
18. Staff engagement sessions being progressed
- Organisational development strategy has been
developed with sessions on “preparing for change” set
up for Nov 17.
What has been achieved so far in Care Communities?What has been achieved so far in Care Communities?

50. - Involvement of the CCG to enable developments outside of
specifications to test different models (see later).
- Using Partnership experience to develop pathway redesign
with Primary Care colleagues and now have a GP lead and
CCICP Manager in each area.
- Rapid response service has been developed with Advanced
Community Practitioners (previously Community Matrons)
and Falls service.
- Multidisciplinary Team meetings in development using risk
stratified information from acute only at this stage
- Investment in social workers aligned to 5 Teams as well as
progressing with mental health case workers
- Involvement of the CCG to enable developments outside of
specifications to test different models (see later).
- Using Partnership experience to develop pathway redesign
with Primary Care colleagues and now have a GP lead and
CCICP Manager in each area.
- Rapid response service has been developed with Advanced
Community Practitioners (previously Community Matrons)
and Falls service.
- Multidisciplinary Team meetings in development using risk
stratified information from acute only at this stage
- Investment in social workers aligned to 5 Teams as well as
progressing with mental health case workers
What has been achieved so far in Care Communities?What has been achieved so far in Care Communities?

51. • Able to respond within 2 hours.
• Over 500 patients have received this new service
with only 13% being admitted to Acute Trust
within 14 days.
• Previously these would have required a GP visit.
• Rolled out across all 5 Care Communities.
• Consultation process completed to update the
JD/person specification to reflect the changes.
• Supported by Intermediate Care to provide Care
provision.
• Really positive feedback from GPs, patients and
staff alike
• Able to respond within 2 hours.
• Over 500 patients have received this new service
with only 13% being admitted to Acute Trust
within 14 days.
• Previously these would have required a GP visit.
• Rolled out across all 5 Care Communities.
• Consultation process completed to update the
JD/person specification to reflect the changes.
• Supported by Intermediate Care to provide Care
provision.
• Really positive feedback from GPs, patients and
staff alike
Advanced Community Practitioners Rapid Response
Service
Advanced Community Practitioners Rapid Response
Service

52. • 203 seen so far from mid-
June to mid-September
• Average 210 bed days saved
• Average age of those seen
81years
• 72% seen & treated at home
previously only 35%.
(NWAS data provide to CCG, September 2017)
Collaboration with NWAS to deliver integrated
falls car service pilot
Collaboration with NWAS to deliver integrated
falls car service pilot

53. What next steps for Care Communities?What next steps for Care Communities?
- Development of roles to support proactive case
management of people assessed as High Risk – Complex
Care Practitioner role development.
- Ongoing Organisational development sessions to
support team building and enhanced skills and roles.
- Complete estates strategy development in line with
increased mobile workforce
- Complete development of a clinical leadership
strategy that is clinically led.
- Development of roles to support proactive case
management of people assessed as High Risk – Complex
Care Practitioner role development.
- Ongoing Organisational development sessions to
support team building and enhanced skills and roles.
- Complete estates strategy development in line with
increased mobile workforce
- Complete development of a clinical leadership
strategy that is clinically led.

54. 1. Chronic and long Term conditions
(heart failure, diabetes, respiratory)
2. Low level Mental health support
3. Care of the elderly and frail.
CCICP clinical priorities agreed for 2018/19CCICP clinical priorities agreed for 2018/19

55. • Procurement – working with CCG to take responsibility for some
non pay elements of care and specialist patient management and
support - Stoma, Catheters and Dressings
• Increased service offers – working to increase services provided to
include – Tier 3 weight management, joint school, SPA MSK and
potentially more
• Work with Alliance to integrate OOHs, palliative services and
primary care urgent response
• Working with Social care to improve contract management for
domiciliary care contracts and bed based community care services
Future Developments (examples)Future Developments (examples)

57. Accountable Care
- Learning to Date
Helen Kilgannon and Sara Radcliffe

58. All homes!
Don’t get hung up on
three letters -
Improving health and
wellbeing is the key!

59. • ICO: providers working in partnership to deliver
better co-ordinated services to improve outcomes,
experience and efficiency.
• ACO: as above, and with a capitated budget,
some commissioning functions, and a greater
focus on improved health as well as improved
services.
• ACS: regional systems of providers and
commissioners working together across STP
footprints
There are:

60. • What’s your staring point? System maturity and relationship maturity
• Who are your neighbours? Primary care engagement key
• What’s the vision and strategy?
• Who’s your architect and who’s the team
– Take responsibility for the whole build, not just elements
What are the foundations?

62. Design Phase
• What do you want from a home …………… not who will
supply materials?
• Balance of form and function (You don’t need to
choose your taps yet!)
• Proof of concept
• Pinch other design ideas!
• Engage NHS Improvement and NHS England

63. Keep Asking, have we…..
• A vision
• Key themes
• Lots of lots of things
• Framing the issues
• Mutually reinforcing the change
• Refreshing the story
• Emergent planning and design
• Many people contribute to
leadership
• Transform how people think
about it
• Maintain and refresh the
leaders’ energy

64. • First step is understanding your boundary
• What matters to you – sustainability, high-tech / low-tech, key
rooms? Ask the question?
• What can you use of the existing build – Assets?
– Statutory (full primary care)
– Voluntary
– Faith and community
• Neighbourhood arrangements
– Who understands them?
• Public health data
What are you building?

65. • CE/ Directors
• Project manager – links with each team
• Relationships - commit to the whole build
• Energy and resilience
• Use specialists!
The build team

66. System Leadership:
3 Core Capabilities
Senge et al 2015

67. • Trusted advisor
• Intentionally building relationships
• Holding up the mirror
• Assume nothing………..
• STOP
• Our relationships and knowledge of the systems help
Kevin - AQuA’s role

68. Let’s build together!

70. Ian Bett, Programme Manager, The Model Hospital
Our Approach to Patient Flow and
Transformation at the Countess

71. There is a major
problem with the
numbers…
There are not
enough doctors and
nurses…
Expectations of care
are changing..
Our responsibility to
our patients and
staff..
1
2
3
4
The Case for Change

72. Win’s Journey
4th March 106 days later 18th June
• Admitted to hospital
• Surgical repair
• Discharged to a
nursing home
4 incidences of Hospital Acquired Pneumonia4 incidences of Hospital Acquired Pneumonia
Grade 2 heel pressure ulcersGrade 2 heel pressure ulcers
15 ward or location transfers15 ward or location transfers
Under the care of 5 consultant teamsUnder the care of 5 consultant teams
11 X-rays – mainly chest11 X-rays – mainly chest
174 pathology tests174 pathology tests
5 units of blood given5 units of blood given
Blood taken 49 times = 482ml, equivalent to 1.5 units
of blood!
Blood taken 49 times = 482ml, equivalent to 1.5 units
of blood!
78 separate issues of drugs78 separate issues of drugs
Cost to the organisation of £32,903. Income of £8,697Cost to the organisation of £32,903. Income of £8,697

73. High
Reliability
High
Reliability
Operational
Transparency
Operational
Transparency
ValueValue
AccountabilityAccountability
Embedding a
Performance &
Accountability
Culture
Embedding a
Performance &
Accountability
Culture
Operational
Excellence
Operational
Excellence
Operational
Renewal
Operational
Renewal
Principles to Our Transformation

74. Creation of a Centralised Hospital
Coordination Centre
October 2017

75. Virtual walls
Patient badge
Equipment badge
Staff badge
The Technology

76. No additional escalation
beds
Reduction in LOS
Reduction in
medical outliers
Reduction of ED breaches
due
to lack of available bed
capacity
Beds are turned over and
available for a new
patient in less than 35
minutes
Reduced locating time of
assets by nurses
Improve efficiency of our
support services e.g.
portering
Improve theatre utilisation
Significant enabler to deliver our savings plan and
improve our patients experience
Significant enabler to deliver our savings plan and
improve our patients experience
Anticipated Benefits

78. For a patient move the average response time is 5.5
minutes and the average job completion time is 10.5
minutes.
Since go live over 116,000 jobs have been completed using the
TeleTracking system, an average of over 600 jobs per day.
We now have sight of our Portering services workload, staffing levels and
performance metrics.
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Mon
Tue
Wed
Thu
Fri
Sat
Sun
This heat map displays our peak times for
jobs being requested.
Porter Request System

79. Installation and Equipment

80. Bed Turnaround Team
Went live 11th
September
11 Staff
Times covered:
08:00 – 20:00
10:00 – 18:00

81. Matching Staffing to Acuity
To be monitored and managed through the Coordination Centre

82. In Summary….
Operational sensitivity
• Situational awareness
• Hyper-acute use of technology
• Transforming data into actionable information
• HROs organise themselves in such a way that they are
better able to notice the unexpected in the making and
halt its development
• Sensitivity to operations
• Leverage technology use
• HROs have well developed situational awareness
• All HRO examples have organised control centres
Managing The Unexpected
Our aim is to be a High Reliability NHS Organisation

83. Our Local Footprint in the Future?

84. Model Hospital
Showcase Event
6th
December 2017
Thank you

85. Improving Hospital Operations
Shantanu Dholakia, MHA, BDS, Client Strategy
Manager

86. Who We Are
85
1st
Retenti
on Rate
26 YEARS
As Industry
Leader in
Patient Flow
97+%
Nine of the last
eleven Baldrige
Hospital Winners
8 of 10
LARGEST
US
HEALTH
SYSTEMS Client Reference
Programme
Members with
Measurable
Outcomes
982+Clients
350K+Acute Care Beds
Industry Leader in
Patient Flow
100% of clients surveyed
said TeleTracking is a part of
their long-term plan.
Winner for “Best
Product for
Improving Working
Practices”
Lord Carter
Hospital
Innovation
Award 2017

87. • What We Do
• TeleTracking’s patient flow solutions create the foundation for driving efficient and safe care in your organisation
Electronic Medical Records
Hospital Coordination Centre and Operational Platform
Staff AssetFacilities
 Staff Engagement
 Contextual Alerts and
Alarms
 Performance Improvement
 Staffing and Scheduling
 Timely Patient Placement
 Increased Bed/Theatre
Turnover
 Procedure Area
Management
 Forecasting and Planning
 Location Tracking and
Delivery
 Align with Patient Needs
 Enable Maintenance and
Sterilisation
Clinical Documentation Physician Order Lab & Pharmacy

88. Coordinat
ion
Centre
• TeleTracking’s Hospital Coordination Centre Model

89. The National Patient Flow Software Implementation
Initiative
NHS Improvement Initiative
Sites

90. • Expected Benefits
1
Evidenced through implementing in over 900 hospitals
Access
Impact
 20-30%
 50-75%
 90%
 A&E 4 hours breaches
 On-day theatre cancellations
 Specialty Transfer denials
Utilisation
 10 -30%
 15-25%
 Theatre session utilisation
 Equipment utilisation
Safety
Impact area
Productivity
Throughput
 0.75- 2 days
 80-90%
 75%
 50%
 ALOS
 Dead bed time
 ITU discharge delays of > 4 hours
 DTOCs
 30-50%
 15-50%
 Medical Outliers
 Hospital acquired pressure ulcers
 15-20%
 5-10%
 Improved staffing productivity through
• Demand and acuity driven staffing: right-sizing workforce
• Reduction in non-value add tasks

92. Integration of
Social Care
Natalie Park
Interim Deputy Director Operations

93. Integration of Health and Social Care
• Why?
• Journey to 1st
June
• Current priorities – 100 days
• Future transformation

94. Why did we integrate?
Transformation of health and social care
- no single part of the system can deliver
effectively in isolation.
Requirement to maximise health and social
work resource for most impact in health and
social care system
•Improve outcomes for people
•Protect people appropriately
•Better able to manage capacity and demand
•Maximise the effectiveness of expenditure

96. Due Diligence…
• Robust programme management
• External DD - KPMG acting for both
• Key areas –
Model of Workforce and Delivery
Finance and Service Specification
Corporate Support Services
Legal contract

98. Issues and Challenges…
• Pensions
• Back Office Support and VAT
• Dependencies with other Social Care Delivery
changes – MH and LD
Collaborative approach…

99. The Legislative Framework of
Social Care
Delegation of statutory duties
can be made in law but the role
of Director of Adult Social
Services is enshrined in
legislation therefore the Director
and Wirral Council retain overall
responsibility. This makes the
relationship between the Council
and Trust Crucial

100. • Delegated Duties under Relevant Social Care
Legislation
• The Care Act duties including
• Safeguarding adult enquiries
• Assessment, support planning and review, promotion of wellbeing
principle and independence
• Mental Capacity Act duties including Deprivation of Liberty Safeguards
• Mental Health Act Duties
• + Relevant social care guidance - including
Employer Standards

101. Enablers
Challenges

102. 1st
June 2017 and Phased Development
• Transition and Mobilisation phase – March 2017 - June 2017.
• Stabilisation phase - Year 1 of contract – June 2017 – June 2018
• Development and transformation phase - Year 2 of contract
onwards - June 2018 
.

103. Referrals received
Individuals ,
carers ,
professionals
EDT
WBC
OOH
CADT/ Gate way
& First Contact
Hosp
Integrated Discharge
Team
POPIN /
Early
intervention
STAR
Reablement
Rapid
Community
Response
Multi Agency
Safeguarding
MASH
Deprivation
of Liberty
safeguard
DOLS
4 Integrated Care
Coordination Hubs
Occupational
Therapy
Visual
Impairment
Team
Admin
Support
Social Care Services
Current
CAT
Care
Arranging

104. Service Activity by Team
Team Active Services %
Rapid Community Response Service 56 1%
Integrated Discharge Team 94 2%
Birkenhead ICCT 1456 24%
Wallasey ICCT 1551 25%
West Wirral ICCT 1282 21%
South Wirral ICCT 992 16%
STAR 185 3%
POPIN 478 8%
Total 6,094

105. Staff Engagement
• Critical !!
• Ongoing – events, briefings, F2F, 1-1, FAQ
• Formal TUPE
• Welcome 1st
June

108. Current priorities – Safe Transfer, Stabilisation

109. Quality Governance & Professional Standards
National , Regional and
Local
Representation at National
& Regional Forums – PSN,
NWSC
Collaboration with National
Transformation
Organisations - AQuA, ECIP
Representation at local level
Senior Change Team
Urgent Care
A&E Board
Internal
Associate Director Role ASC
Clear Link to Director of Nursing &
Quality Improvement
Staff engagement / wellbeing
Dedicated Professional Standards
forum reporting to EWC and
Partnership Governance Board
Incident reporting, citizen feedback,
risk management reporting to QSC
Career Progression Frame work
Internal Audit programme
Key Performance Indicators
Contract Monitoring
Contractual &
Statutory
Assurance to WBC on social
work standards best practice,
fulfilment of statutory duties
Professional Standards
arrangement via sc75
Agreed audit programme - 7
key areas plus bespoke
Shared learning across wider
social care system
Legislation, Practice Guidance, Professional Capabilities Frame Work,
Standards for Employers of Social Workers, HCPC Standards of Proficiency

110. KPI’s & Activity Measures
Ensuring A Timely Response
•KPI – Length of Time between contact and assessment
•KPI - % Assessment Notices where core assessment completed with 24 hours
•AM – Reduction in call waiting times at CADT from 14 mins to 3 mins
Protecting Vulnerable Individuals
•KPI- % Safeguarding concerns completed in 24 hrs.
•KPI- % Safeguarding enquires completed in 28 days
•KPI- % Dols completed within Statutory Timescales
Promoting Independence
•KPI -Nos of admissions into Res/ Nursing Care
•KPI- % Older People at 91 days post discharge from Hospital into Reablement
•KPI - % Individuals who have had an annual review
•AM -% requests that are Self Assessments

111. Management of Community Care Budget
Budget draw down circa £55
m

112. Supporting our Staff to be outstanding through…
Developing Culture – Values, Beliefs, Behaviours
•Leadership for All
•Quality of care – safety culture - raising concerns
Staff engagement and Wellbeing
Promoting service user involvement – Your Voice

113. Feedback from Staff
• . ‘ I feel proud
‘I do feel this is already
encouraging better
integrated team working
across therapies,
nursing, and social care’
‘I feel that we have
been welcomed with
open arms and are
considered a
valuable asset to the
Trust’
‘Relationships with health
colleagues have improved
significantly’
‘easier to be able to talk and
support each other face to face
than trying to work alone and
search for staff members by
phone.’
‘ I feel proud to be a member of Wirral
Community NHS Foundation Trust and thank
them for the warm welcome and support
received. I look to forward to what the
future unveils’

114. And some of our citizens…..
I was pleased that I didn’t
get passed from pillar to
post and that I had 1
worker to deal with, thank
you as it has reduced the
stress’
It was a really good service, I had visits from
enablers , office staff and Occupational Therapists,
who all ensured I was able to manage’
‘My mum came out of Hospital and as a family we took care of her over
the weekend, her first care visit was last night and the team have been
just Absolutely brilliant. this is all new to us and we were desperate to
get Mum home. Once again, thank you so much for all your help and
the advice and information you gave me’
‘the simple things like putting my clothes
on was a struggle but now I have had a
STAR service, they worked with me and I
can now do it again with aids to support
me’

115. Number of key Areas for Transformation
Internal Service Redesign & Development
Integrated Gate way
Early Intervention & Prevention offer
Safeguarding
Further development of ICCTs – Lead Professional Model & MDTs
Care Arranging Team
Improving Pathways and the customer journey
Single Assessment
Trusted Assessor – internal – reduce duplication
Transitions services - LAC
Options for IT solutions – Care Records
Wider System Redesign
Urgent Care Redesign
52 – 9 – 4 – 1 Place Based Care Redesign
Trusted Assessor & Provider Led Reviews - Supporting Market Sustainability

118. Developing Person Centred Nursing
Associates
Avril Devaney MBE
Director of Nursing & Therapies
Cheshire & Wirral Partnership NHS Foundation Trust
Visiting Professor at The University of Chester

119. Who is in the Cheshire and Wirral Partnership

120. Our Focus

121. What is a Nursing Associate?
• Build the capacity and capability of the health and social
care workforce
• Facilitate the provision of care across health and social
care through the introduction of a role with a flexible and
portable skill set
• Provide a bridge between the non-regulated care
assistant and nursing workforce
• Deliver direct and fundamental care to patients
• Widen access and entry into the nursing profession

122. Nursing Associate

123. Registered Nurse

124. Advanced Nurse Practitioner

125. Nursing Associate Contribution to Skill Mix

126. Trainee Nursing Associate Placement Circuit
& Curriculum
• All of our nursing associates are completing three equal Work based learning
(WBL) placements each year.
• During these placements the Trainee Nursing Associate (TNA) experience
mental health, learning disability and physical healthcare at home, close to
home and in hospital.
• TNAs spend one day per week in university, three days per week on their
WBL placement and one day a week on a spoke placement.
• All area of curriculum are integrated in terms of specialities. There are no
branches within the curriculum programme.

127. Supporting the Trainees