Tees Esk and Wear Valleys NHS FT (TEWV) is a significant partner in the development of a new care model for Harrogate and Rural District. Six health and social care organisations came together locally to become one of fifty vanguard sites in England in 2015. Now in the third and final year of the programme, TEWV has taken on a lead role in developing a Quality improvement system for the partnership to increase the impact and sustainability of the new care model (NCM). From 2018/19 the NCM must be self-sustaining, in particular, by delivering a significant reduction in avoidable admissions to secondary care. The 'What Matters to us' programme aims to dissolve the boundaries between health and care organisations to deliver truly person-centred care which increases people's health and well-being and reduces dependency on the health and care system.
What We Did
Tees Esk and Wear Valleys NHS FT (TEWV) is a significant partner in the development of a new care model for Harrogate and Rural District. Six health and social care organisations came together locally to become one of fifty vanguard sites in England in 2015. Now in the third and final year of the programme, TEWV has taken on a lead role in developing a Quality improvement system for the partnership to increase the impact and sustainability of the new care model (NCM). From 2018/19 the NCM must be self-sustaining, in particular, by delivering a significant reduction in avoidable admissions to secondary care. The ‘What Matters to us’ programme aims to dissolve the boundaries between health and care organisations to deliver truly person-centred care which increases people’s health and well-being and reduces dependency on the health and care system. TEWV has made a significant contribution to this from the outset providing a pivotal role between primary, community, acute, mental health, social care and voluntary and community sector.
TEWV’s contribution of mental health nursing and advanced practice roles to an emerging integrated model of care created a number of opportunities to provide more holistic care, including increasing awareness of mental health conditions and skill sharing. It also provided an opportunity to share tasks and interventions which the mental health staff wouldn’t usually undertake. For example, by training the mental health nurses in basic nursing interventions, a lady who was experiencing anxiety and low mood but required regular wound redressing could be supported by the mental health nurse as opposed to having two staff visit. Their role also consists of educating colleagues in the use of basic mental health interventions such as capacity assessments, mood assessments, and general advice. Helping their colleagues to do a basic capacity assessment prior to treatment has led to a reduction in the number of referrals to secondary mental health services for capacity assessments.
Education and advice with the management of dementia and challenging behaviour has supported the reduction in unnecessary referrals to secondary mental health services. For example, by providing intensive support to a nursing home which has gone into special measures, GPs and other staff felt sufficiently supported and chose not to refer all the residents to the Community Mental Health Team.
Working alongside the Living Well Team (Local Authority) they gave the staff confidence to work with people who experience chronic mental health problems and helped them work with an individual who ordinarily wouldn’t not have been able to access their services.
As the model is refined and moved into business as usual from 2018/19, it is critical that both commissioners and providers are confident that it will deliver good outcomes for people as well as a sustainable and affordable NCM. Implementation of TEWV’s Quality Improvement System (QIS) and Purposeful and Productive Community Services (PPCS) methodology across all partners, provide a common and robust approach that will give that confidence. TEWV has provided the staff from all partners with the tools to be able to manage their workload in a radically different way. Using the LEAN methodology and promoting the ethos of ‘completing today’s work today’, removing waste from the system and increasing the value for the local community, the staff from all partners have contributed in the design of a truly integrated service. Introduction of the key concepts of PPCS has created a single integrated service model: Integrated Response. This is currently being tested and the model continually refined to meet specific outcome measures.
The staff agreed the motto of ‘One team, One Vision, One Goal’ and designed the following processes to support delivery of a multi-agency care model which is truly joined up:
* A single referral and allocation process for those over the age of 18 years and have a high risk of admission in the next few weeks or an increased frailty.
* A single assessment and care plan that will be inputted into one main recording system (SystmOne) and accessed by all key stakeholders.
* daily meetings with all partners present to discuss, agree immediate actions and work toward specific recovery goals as agreed with the individual to keep them safe and independent at home. Participation includes: mental health, social care, GP, community Nursing , OT physio, voluntary sector.
* Core activities as a ‘team’ and agreed the use of electronic diaries under one system so every one can access. The purpose is to manage the flow of demand against capacity and ensure the work is levelled across the team.
* A core leadership team of clinical leads from all partners will meet daily to support the main team and each other in unblocking obstacles which may present in getting someone the care or intervention they need swiftly to keep them at home.
TEWV are also providing intensive senior management and team management support, working alongside peers from the partner organisations to coach them in what is necessary to ensure the sustainability of the new way of managing the demand and flow within the new integrated service.
Wider Active Support
TEWV is working alongside the following partners who make up the Vanguard programme:
*North Yorkshire County Council – social care and public health
* Harrogate District Foundation Trust
* Yorkshire Health Network (GP Federation)
* Harrogate District Council
* Community Voluntary Sector
* Harrogate and Rural District Clinical Commissioning Group.
Strong governance arrangements are in place, led by the Chief Executive Officers who make up Harrogate Health Transformation Board (HHTB), which in turn links to the North Yorkshire Health and Wellbeing Board and the Sustainability and Transformation Partnership locally. Colin Martin, TEWV’s CEO, is the Senior Responsible Officer for this phase of the programme on behalf of the HHTB.
TEWV has committed significant senior leadership capacity and expertise in QIS, working closely with all partners and the cross-system Programme Management Office and also the national NCM team.
As part of the Vanguard Initiative, there has been a number of engagement sessions to include the community and staff. Using a World cafe Style approach to gain understanding from the local community brought about the logo ‘What Matters to Us’ and gave a platform for the focus of the vanguard to take into consideration the following key requirements for moving forward;
*Joined up care to include GPS, community nurses, adult social care, occupational therapy, physiotherapy, mental health, geriatrician and voluntary sector.
* Avoid duplication of visits and assessments
*Single assessment process
* Single care plan
* Offer early intervention, prevention and promote self care through education, advice and training focusing on falls, mental health and strokes.
* Better coordinated health and well-being which includes voluntary and community sectors, local council services, police, fire and rescue services.
* Reduction in unnecessary hospital admissions and attendances at A& E departments.
A staff engagement survey was undertaken earlier this year which gave a clear message that we needed to do more to involve the staff in the development of the NCM. As part of implementing phase two, TEWV was able to ensure significant protected time was built in for staff across all partners to design and build the next stage and be involved with the development of the day-to-day functions of the refined service. Feedback at the end of a development week was consistently high and demonstrated they felt involved and could influence the future model.
With regards to future co-production, phase two implementation built in the following:
* Clear remit to ensure 2-3 recovery goals are co-produced at the point of initial assessment of need which will be monitored daily as part of the multi-agency meeting.
* Re-evaluate the staff position each month and feed any learning into the final analysis.
* developing engagement opportunities such as quality improvement cafes with staff and service users based on the successful Swedish Esther Model.
Looking Back/Challenges Faced
At the outset of this challenging programme, back in 2015, we would have implemented TEWV’s QIS methodology. The approach enables strong and consistent engagement with staff. The methodology has a number of significant benefits that the partners are onyl now benefiting on;
* Co production of the approach
* An evidence base for continuous improvement
* The ability to sense the impact of change and continually adjust and improve close monitoring of key metrics associated with quality, cost and activity.
The success of the NCM is determined by its affordability and sustainability. Even if the model delivers great outcomes for service users, if it is not affordable in the long-term, it cannot continue.
The introduction of the TEWV QIS methodology provides a much more robust approach to ensuring that only successful elements which have an impact are taken forward and also that we jettison elements that are not succeeding as quickly as possible through the use of PDSA cycles. In the transformation of care in a complex adaptive system, it is important to fail fast, learn and adapt as it is to succeed. Prior to the implementation of the QIS methodology, the partnership had limited insight and evidence into what was working and why.
In terms of sustainable products to underpin integrated and productive working, staff have created the following;
* A clearly defined staff handbook was developed for all staff working in the new service. This detailed all the new processes which underpin the new way of working and delivering multi-agency care.
* daily meetings for 30 minutes with the leadership cell that consists of all partners.
* Daily, weekly and monthly monitoring and review of data, key performance indicators and processes are built into the model to ensure we quickly identify;
What works well
What doesn’t work well
What we need to test differently next week
How are we communicating this to our key referrers and
This will include all staff to ensure they are an active part of the evaluation and future development in addition to embedding the PDSA cycle into their daily routine.
* Every 30 days feedback the outcomes and progress to the wider community services and partners though an organised event and shared by the team, not just by management.
In addition, TEWV senior management and leadership support will work alongside peer management from other partners to mentor and share good practice with a view to ensuring the new way of working becomes embedded across the health and care system.
Sustaining the specific mental health clinical interventions into care homes with the view to reduce referrals to secondary mental health services, includes the development of screening tools and attending clinics alongside GPs and community nurses.
Evaluation (Peer or Academic)
The Vanguard NCM programme has commissioned an independent evaluation by Sheffield University. This will assess the impact of the NCM from a quantitative, qualitative and health economic perspective.
Key metrics for the initiative are as follows;
* reduction in attendance in A&E for 65+ years
*Reduction in NEL admissions for 65+ years
* Reduction in emergency bed days
* Reduction in the number of referrals from care homes to mental health service
* Reduction in the number of admissions into secondary mental health inpatient units for 65+ years
* Reduction in the number of people admitted with 2 or more admissions in the last 12 months.
* Reduction in the number of GP visits
* Increase in the use of step up community beds
* % in nil social care packages at the end of reablement.
Baseline and targets have now been established and the metrics are reported quarterly to the national NCM team to monitor progress. Since the full roll out of the NCM in November 2016, little impact has been demonstrated although there has been significant evidence of qualitative improvement gathered through service user stories.
The adoption of the TEWV QIS methodology and intensive implementation has been agreed to enable a much more robust approach. This is in response to the limited impact shown to date and the need to embed an approach all partners, and commissioners in particular can have confidence in.
As a vanguard site, we are committed, as partners, to sharing and spreading our learning both regionally and nationally. The national Team facilitate many opportunities to spread learning and we have been invited to present at a major national conference in June to showcase our work and early learning.
We are in close liaison with other Vanguard sites across England and share learning through many informal and formal opportunities including fortnightly teleconferences, monthly communities of Practice and large-scale conferences. As part of the conditions of the transitional funding in 17/18, we are required to share our learning in particular on the integration of mental health services into our new model.