This document outlines the West Wakefield Health & Wellbeing initiative, which aims to improve health outcomes through an integrated model of care. Key elements of the model include: - Establishing an information hub and integrated teams to coordinate proactive care. - Expanding access through digital tools, extended primary care hours, and initiatives like a schools app challenge. - Implementing programs to address local health issues like obesity and oral health. - Facing challenges in workforce, technology, and governance while accelerating the pace of change.

2. West Wakefield Health & Wellbeing
MCP Vanguard
Dr Chris Jones, GP Chair, Programme Director
The Five Year Foreward View
Sharing Best Practice
Open Forum Event Manchester
Dec 9th 2015
@westwakefield www.westwakefieldhealthandwellbeing.nhs.uk

3. @westwakefield www.westwakefieldhealthandwellbeing.nhs.uk
Contents
1. Background and context
2. Rationale for change
3. The model of care
4. Some tangible changes
5. Challenges

4. @westwakefield www.westwakefieldhealthandwellbeing.nhs.uk
Networks 3,5 and 6
• 17 Practices
• 152,000 patients
1. West Wakefield’s 3 networks

5. 1. Local health profile
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
High mortality rate high for
cardiovascular, respiratory
disease and cancer in under
75’s
High rate of tooth decay in 5
year olds
19.6% of children in year 6 are
obese
High rates of teenage
pregnancy, alcohol related
admissions, road injuries and
deaths.
Low rates of breast feeding and
high rates of smoking in
pregnancy.
Wakefield 2015 Health Profile

6. 2. Rationale for change
NATIONAL
• Demographic changes - Ageing population, increasing burden of LTC
• Pressures on primary care
LOCAL
• Meeting the Challenge: Bed reductions
• Pressures on A&E attendances
• Workforce challenges: GP and nursing
• HealthWatch Young Persons Survey on GP access
So immediate pressures on hospital services which will worsen, with access
difficulties and a workforce in crisis lead to the creation of three hypotheses…
@westwakefield www.westwakefieldhealthandwellbeing.org.uk

7. @westwakefield www.westwakefieldhealthandwellbeing.org.uk
2. The Hypotheses
50% of work done by GPs could be carried out by a more
cost effective resource
30% of elderly people admitted to hospital acutely for a
short stay of between 0 and 5 days do not need to be
admitted and could be cared for differently in an
alternative setting
30% of patients occupying an acute hospital bed do not
need to be there because their episode of acute care is
over
We have devised 90 logic
models with which to
evaluate the programme
and test these
hypotheses.
The new model of care
must also achieve the
three objectives of the
Triple Aim.
Lower
Cost
Better patient
experience
Improved
outcomes
THE TRIPLE AIM

8. Disruptive
Prevention
Self Care Care
Navigation
Improved
Access
Support at
Home
Admissions
Avoidance
Early
Supported
discharge
Schools App Challenge
Oral Health
• Fluoride Varnish
• Flouridation
• Joint consent
Childhood Obesity
Mental Health
Digital
• Service Directory
• Symptom Checkers
• App Library
• Big White Wall
Patient Education
Expert Patients
Care Planning
Social Prescribing
Micro-commissioning
Care Navigators
• Phone, Email,
Chat, Web
• ‘Apple Store’
Kiosks
Care Navigation App
7-day service
Physiotherapy First
Pharmacy First
Pharmacist in GP
Social Worker
Mental Health Worker
Triage
Video Consultations
E-Messaging
Shared visiting service
Care Home ProjectHealthPod
Integrated Multi-Professional Community Teams inc Nursing, Carers and VCS
Information Hub
Proactive Care
Primary Care Champions Consultants in the Community: Elderly, Cardiology, Respiratory, Mental Health
Intermediate Tier Beds in CommunityIntensive Home-Based Therapy
For physical and mental health
Connected Home
Prime Minister’s Challenge on GP Access Connecting Care
3. The model of care
Shared records: Citizen-held care record
“Through expanded primary care, proactive teamwork and new technology to deliver
health and social care at scale to the GP registered list of West Wakefield”
Working with Wakefield CCG and building on the Prime Minister’s Challenge to generate
primary care workforce engagement as a key catalyst for lasting change.
@westwakefield www.westwakefieldhealthandwellbeing.org.uk

9. The Vision
GP
Admissions avoidance
Early Supported Discharge
Call
Centre
Central Hub
Waterton House
Connected
Home
Assistive
Technology
Improved
Access
Integrated Teams
Video, E-messaging
HealthPod
Extended Hours
Care Homes
Consultants
Citizen-held care record
Care Navigation
Digital self-care
Social PrescribingUnified Communications
Federation & Collaboration
Pharmacy First
Physio First
Nursing United Carers Framework
Provider Alliance: MYT, SWYPFT, WMDC, WDH, Nova (all VCS), Age UK, YAS (111,999), LCD, Spectrum
Integrated Teams
C3 Ops Centre
@westwakefield www.westwakefieldhealthandwellbeing.org.uk

10. @westwakefield www.westwakefieldhealthandwellbeing.org.uk
4. Integrated MDT
Elderly Care
Consultant
Respiratory
Consultant
Community
Psychiatrist
VCS
Specialist Nursing
Teams
Therapists
Social Worker
Community
Matron
Community Nurse
Community Mental
Health Nurse
Care Navigator PharmacistHub Manager
Community
Cardiologist
Hub Clinical Lead
Practice Nurse GP
Acknowledgement for images: Lesley Carver NHS NW Surrey CCG
Co-located
Shared mission
Shared culture
Shared records Mutual trust
Authority to act
Daily virtual meeting
Proactive approach
Information Hub Access 24/7
Tactical TeamsGenerates Care Package
Strategic View
Health Visitor

11. @westwakefield www.westwakefieldhealthandwellbeing.org.uk
4. Information Hub
GP System Notifications
GP System Population Data
Ambulance Service
A&E Metrics & Notifications
Hospital Admissions
Hospital In-patient Status
Community Notifications
Met Office
Local Authority Records
Mental Health RecordsPublic Health Statistics
Police Comms Link
Housing Comms Link
Fire Comms Link
Smart Home Notifications
Informs the Integrated MDT

12. 4. Citizen-held care record
• Owned by the individual, cloud based
• Fully sharable
• Health and well-being information, LTC management, care plans, social
network, social care package data, EOL planning etc.
• Complementary to NHS record
• Several example in development
– Patient Knows Best
– Leeds Care Record
– Kirklees Self care Hub
– Vitality/Digital life Sciences
– eRed Book
– Vitrucare
@westwakefield www.westwakefieldhealthandwellbeing.org.uk

13. • Growing array of monitoring and wearable tech
• Develop the smart home concept
• Start with social housing stock – all have broadband
• Already wide array used in Wakefield
• Make people feel connected, safe and looked after
• Detect signs of illness. Raise alerts
4. Connected Home
@westwakefield www.westwakefieldhealthandwellbeing.org.uk

14. @westwakefield www.westwakefieldhealthandwellbeing.org.uk
4. Extended Hours
• 6.30pm – 8.00pm Weekdays,
• 8am – 8pm Weekends
• Routine & Urgent appointments
• Routine booked during normal hours
• Urgent from 111 as ITK message into
SystmOne
• Staffed by internal personnel
• Run from dedicated premises inside high
quality new build Health Village
• Augmented by the 24/7 digital access
solutions
NEXT STEPS
 Create consistent service across
three networks to cover full
population of 152,000 with
consistent offer
 Consider hours of operation
 Broaden skill mix

15. 4. Extended Primary
Care Team
• Physiotherapy First
• Pharmacy First
• Heath & Wellbeing Worker
• Care Navigators
• Health Champions
NEXT STEPS
 Pharmacist in General Practice
 Mental Health worker
 Community Consultants
 Social Worker
 Primary care
0
20
40
60
80
100
120
140
Physio First Contacts
Viral cough
No cough Fever
without viral
symptoms
Sore throat
HayfeverAllergy
symptoms
(skin)
Insect
bite/sting
Oral thrush
Vaginal
thrush
Teething
Cold sore
Headache/mi
graine
Threadworm
s
Other

16. 4. Pharmacist in General Practice
• 0.5 Session per 1,000 patients
• Post-discharge medication reconciliation
• Medication reviews, reduction in polypharmacy
• Minor ailments advice
• Interface with community and hospital pharmacists & CCG MO team
• Management of repeat prescribing process and formularies
• Implement MRHA guidance, safety alerts and changes in indications
and availability
• Medicines advice to whole team

17. 4. HealthPod
• Out reach
• Hard to reach
• Menu of services
– CAB
– Housing
– Carers Wakefield
– Age UK
– Youth groups
– Mental health worker
– Sexual health outreach
– and more…
• Own Twitter account
• Tracking app
Wakefield Clinical Commissioning Group
Working in Partnership

18. 4. Care Navigation
• Care Navigators
• Training Course devised
• Over 70 trained
• Supported by primary care health champions
• Using Service Directory and other on-line tools

19. 4. Care Navigation App
• Web-based decision tree
• Public access

20. 4. Service Directory

21. 4. Kiosks
• Care Navigation App & web site
• Kiosks in Reception
• Part of West Wakefield web site
• Service Directory
• Real-time signposting to resources
• App Library

22. @westwakefield www.westwakefieldhealthandwellbeing.org.uk
4. Schools App Challenge
• Year 6
• Design a health and wellbeing app
• Think about healthy living and own
family and friends
• Strong prevention messaging
• Supported by Microsoft
– Touch develop
– Mentors by Skype
• Teamwork, coding, presentation skills
• Dragon’s Den style judging
• Engagement with Schools
NEXT STEPS
 Roll out to wider population
 Version 2.0
 Lessons learned
 Sponsorship
Team Friendship Forever (Dragon in the Attic)

23. 4. Dragon in the Attic
@westwakefield www.westwakefieldhealthandwellbeing.org.uk

24. 5. Challenges
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
• Workforce
• Technical Infrastructure
• Estates
• Provider Management
• Delivering at Pace
• CCG Governance
• Local Engagement

25. MCP
Network 3
Network 5
West
Wakefield
MYT
Nova
CCG
(partner)
WDHSWFPFT
Spectrum
Age UK
YAS
Fire &
Rescue
Local
Authority
HOS
T
• Shared accountability
• Hosted by West Wakefield – contract holder
• Chaired by CJ
• Supported by JJ
• CCG as invited attendee, not present for
commercial/sensitive provider discussions
What about other providers?
To develop:
• MoU/Business Rules
• Terms of Reference
6. Accountability Model
@westwakefield www.westwakefieldhealthandwellbeing.org.uk

26. MCP
NHS England
Connecting Care Executive (Commissioning)
Adults, Children & Young People
Vanguard
Subcommitte
e
CC Health &
Social Care
Partnership
Operational
Commissioning
Group
Wakefield CCG
Wakefield District
Health and
Wellbeing Board
Wakefield
Council/Cabinet
6. Governance model
@westwakefield www.westwakefieldhealthandwellbeing.org.uk

27. 7. Milestones
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
• Hub Manager in place 12/12/15
• Mental Health Worker roles embedded in Hub 11/01/16
• CrossLead Senior leadership event 21/01/16
• Schools App v2 Judging 28/01/16
• HealthPod 2 operational 01/02/16
• Community Consultants in Hub 15/2/16
• Information Hub IOC and SOP established 18/01/16, Full
07/03/16