North Lincolnshire CCG - transforming services for the frail and elderly. Slides from the impact and celebration event held in London on 24 February 2015.

1. NHS NORTH LINCOLNSHIRE CLINICAL COMMISSIONING GROUP
1

2. 2
North Lincolnshire
Transforming Services for the Frail and
Elderly
Caroline Briggs
Director of Commissioning
North Lincolnshire CCG

3. 3

4.  Population c.167,000
 328 sq. miles
 Dispersed population across urban Scunthorpe, 6
market towns and 80 villages.
 Population growth - increased by 9.5% from 2001 to
2011 compared with 7.9% nationally
 Demographic older than national average, with a
predicted 21.3% over 65 by 2018 compared to England
average of 18.5%.
4
North Lincolnshire

5. 5

6.  CCG - 19 GP practices
 North Lincolnshire Council - Unitary
 Northern Lincolnshire and Goole NHS
Foundation Trust – Scunthorpe General Hospital
and community services
 Rotherham Doncaster and South Humber NHS
Foundation Trust – Mental Health Services
6
Local structure

7.  Health and Wellbeing Board identified Frail and Elderly as a
priority for focus in 2013
 Population context
 Healthy Lives Healthy Futures - creation of future sustainable
health and care services across Northern Lincolnshire
 Increasing admissions to hospital
 22% increase in 65-74 in last 12 months
 8% increase in 75+ in last 12 months
7
Why Frail and Elderly?

8. 8

9.  NHS IQ team engaged to support how we could
work together across the partners
 Workshops - Alliance included staff from CCG, GP’s,
Acute hospital, Community services, Council from
across different areas, commissioning support, older
people mental health team, NHS England,
Healthwatch
 6 workshops held March to October
9
Transforming Care

10. 10
Partners in Frail and Elderly
Programme

11. “To keep well, I need to be able to live as independently as possible so
I feel in control and can pursue my life purpose (which may well be
caring for others), supported by a close social network of family,
friends and share and understand my experience. I want one main
trusted contact with whom I feel safe, who is linked the health and
care ‘system’ (not necessarily a clinician). I want that person to respect
me, and guide me. I want them to join up conversations between
services – especially concentrate on coping and keeping well; doing as
much as possible to care for with support of my family and friends. This
person also needs to understand my story and see being impacts on my
physical wellbeing – and vice versa. Preserving my mobility is special
because it’s about me staying in control and being independent. The
NHS has to recognise my physical and emotional well-being to keep me
well. Often talking and being listened to by helps me with the
emotional stuff - more than clinical people
11
What do people want?

12. 12

13. • Model for future services for frail and elderly
created – trialled in ‘perfect weeks’
• Design of approach to Better Care Fund plan –
Approved
• Detailed business cases being finalised
• Significant target reductions in non elective
admissions 11.5% on Nov 14 baseline
• Changes being implemented
13
Impacts of Programme

14.  Prevention
 Well being hubs supporting independence and reducing isolation
 Extra support to carers
 Team working with Care homes to support them to keep residents well
 Out of hospital support
 Enhanced Locality teams working with primary care
 Rapid Assessment within and hour and time limited support at times of
crisis
 Ambulance service working with community teams to access support at
home rather than take to hospital where appropriate
 In hospital
 dedicated multi disciplinary Frail and Elderly Assessment and Discharge
teams – experts to proactively manage care and plans for discharge
 7 day social work input
 Older peoples mental health liaison team
14
Future Model for Frail and Elderly

15. 15

16.  I will be supported to maintain my independence for as long as
possible
 I will feel confident to remain living at home for longer
 I will be in control of long term conditions and helped to manage it
appropriately
 I will feel safe
 I will have my health and care needs met closer to home
 I will feel part of the community and are less isolated
 My carer will feel able to continue in their caring role
 I will be supported back into the community following a medical
intervention
16
What does this mean for individuals?

17.  Relationship building through sustained development
over a period of time
 People working together who would never normally
do
 Tools and techniques learnt and practised in context
of what we want to achieve
 Workshops provided a ‘safe’ environment to think
differently and lose organisational boundaries
17
Benefits of NHS IQ support

18.  HWB adopted a suite of documents to support integrated
working – including recommending the innovation culture tool
for use with teams
 Webex’s being organised for how to use NHS IQ innovation
culture and collaborative teams tool to share with wider
audience across partners
 Learning and individual development
 Tools used in other programmes including driver diagrams
18
Broader outcomes

19. 19
 “Had the programme been very rigid it would not have been
successful at all”
 “complete tailoring to us”
 “The programme has given people the space to have these
discussions”.
 “Better outcome than the traditional approach”
 “Practical sessions and meaningful discussions”
 “Made me feel brave enough to share difficult experiences”
 “Exceeded my expectations.”
 “Really thought provoking.”
 “Made me think outside the box.”

20. ↑Permission to try – Perfect Week
↑Ideas developed through the discussions with wide range of inputs
– RATL
↑Relationships
↑Pace of discussions
↑Excellent and flexible facilitation – the car park discussion!
↑Good engagement and attendance throughout including GP’s
↓Frustrations when people had missed one of workshops and
needed to catch up!
↓We failed to get Consultants engaged
↓Realising we have lots of people across our system who ‘do’
engagement, leadership and a gap re delivery and measurement
(NHS Change Mats)
20
Highs and Lows!

21. Yes!!
But
 needs to be the right challenge – we chose
well
 Would seek stronger sign up at the start from
all
 Would aim to share the workload a bit more
to get real buy in from key partners
21
Would I do it again?