The Meir Partnership Care Hub has brought together and co-located Health, Social care and Community practitioners to respond to individuals within five GP practices. Both the local authority and Combined Healthcare NHS Trust have brought in existing partners to develop and focus third sector provision around this locality. The aim is to develop a ‘ground-up’ model based on the following principles: Putting the person at the heart of what we do; Working to resolve/address needs as opposed to simply referring on; Identifying sustainable solutions which prevent individuals from returning to the system or entering crisis and causing high costs to the system
What We Did
There is a strong strategic ‘push’ at a national and local policy level for Health and Adult Social Care organisations to join together to deliver integrated services around GP patient populations. This is directly linked to the development of the STP Plans and MCP models of care which are being considered as the preferred direction of travel for future services in North Staffordshire and beyond.
Locally, a prototype model – the Meir Partnership Care Hub, a core team of Adult Social Care and Mental Health Practitioners with pull-on from other agencies including: SSOTP, the voluntary sector, Fire and Police – has been operational since October 2016. The Meir Partnership Care Hub has brought together and co-located Health, Social care and Community practitioners to respond to individuals within five GP practices. Both the local authority and Combined Healthcare NHS Trust have brought in existing partners to develop and focus third sector provision around this locality.
The aim is to develop a ‘ground-up’ model based on the following principles:
• Putting the person at the heart of what we do
• Working to resolve/address needs as opposed to simply referring on
• Identifying sustainable solutions which prevent individuals from returning to the system or entering crisis and causing high costs to the system
This agreement has been underpinned by a long standing formal partnership between the City Of Stoke on Trent Council and North Staffordshire Combined Healthcare. The Section 75 (Health and Social Care Act) agreement has been in place for nine years and all mental social care services have been integrated within NSCHT.
More recently the development of the Cooperative Working model with the local authority and partners from statutory and third sector providers has provided the opportunity to have agreed principles and values which in turn offers greater cooperation and wider partnership opportunities.
This model does not require formal structural integration but is built on the agreement between the City council and Combined healthcare to co locate and share some management functions to form a team which is based in the locality and focused on a defined GP population. This forms the base for other services to link directly into a systems focused approach which reduces the need for “referral on” and enables services to be pulled in around the person based on what they need and their expectations. The basic principles of having a listening conversation, agreeing goals and working across services to provide a coordinated response with defined outcomes is the essence of the model. Referrals are taken directly into the team or via existing routes and the team then stays with the person until some resolution to the issues presented has been reached or there is clearly defines service delivery plan in place.
The ability for local authority social work staff and mental health professionals to support the planning and direction of the work undertaken with someone accessing the services has been uniformly well received by both the people using the service and by professionals. Being able to respond quickly and without further referrals between services has significantly improved the response and the outcomes for people. Other professionals form Primary Care, Community Police Services and the Fire Service have been available to be consulted or involved in the solution focused interventions which provides the opportunity to deliver long term solutions with an holistic focus.
Some of the feedback indicates the positive impact
“I honestly don’t think I would be here (without the support); life was that desperate – it really was. It was really hard for Nick; I was convinced I wasn’t good for him. I think I can honestly say that it’s saved us because things were that bad.” – Karen, aged 45
“I fully appreciate this care programme. It’s a real help for patients who would like to stay at their own home and it helps to keep their dignity and independence. I hope this programme will continue getting better and will attract enough funds to keep it going.” – Meir GP
“The time process has been very quick for the referrals and for us putting action plans in place. From Bianca’s point of view, something that would normally take up to eight weeks to turn around we had everything there within a week; it’s about putting in a plan that supports that person sooner rather than later. Also, people are there in the office if we need to ask questions rather than emailing or ringing.” – Glynis, Young Adults CPN, Meir Care Hub
“It’s been great. We’ve had support and support that we didn’t know was out there. They have really boosted her and picked her confidence up.” –
“In the ‘old world’ we would have had to have a referral for the CPN from the GP and would have been waiting a couple of weeks for that. Now we can just ask them to come out.” – Sharon, Social Worker, Meir Care Hub
Data capture on the Meir Community Wellbeing team identified that around 25% of incoming demand is more complex than traditional adult social care and require a multi agency approach
A recent analysis of Combined HealthCare incoming demand suggested that around 12% of individuals are also known to Adult Social care services .
75% of cases have some level of mental health issue which have required a level of intervention. This has included:
• Advice on referral to Team or allocated worker
• Signpost to other community/third sector service
• Joint visit to contribute to initial assessment
• Take lead responsibility for the case with integrated social care/health focus
Impact on Mental Health referrals to Access
Data for referrals to the Mental Health Access Team for people who are registered to the GP’s in the Meir area area:
• January 2016 to December 2016 Total 291 – direct from GP 143
• October 2016 to December 2016 Total 53 – direct from GP 143 ( these figures include referrals taken at Access but passed to Meir Team
• 99 referrals have been taken at the Meir Team 75% of which have had some M/H component
• 28 cases have a direct and significant involvement from the Mental Health worker
(This based upon the current input from M/H of 1 x 0.6 Mental Health Professional and 1x 0.6 STR)
Indications from the M/H worker and the Wellbeing Team manager are that in the existing system.
The majority of these cases would not have been picked up by the metal health service at this point and access to the service would have potentially been at acute level as the issues escalated. The ability to work directly with the wellbeing team has reduced this delay, improved the service by dealing with the issues as whole and reduced the referrals on to acute or secondary care.
From the perspective of the wellbeing team the co-location and joint working approach has been increasingly effective for the individuals involved and more efficient in terms of outcomes and time.
On average it takes 52.2 days for the care hub to resolve the problems presenting to them based on ‘What Matters’ to individuals, but could statistically take up to 143.1 days based on the current variation in the system. The chart below shows how long it takes to resolve similar problems in the current Adult Social Care system based on taking a sample of random cases out of Care First IT system. That data in this chart suggests the average number of days to be 165.4 but could statistically take up to 565.9 days based on variation in the system.
This comparison needs to be treated with caution as there are still some cases open to the Meir Team that have been open for 133 days due to ongoing system conditions i.e. lack of stay at home support, etc. Once closed, these cases will increase the average end to end time and the upper limit which is why resolving system conditions is critical in keeping the system stable.
The new service has also looked to develop the local community. Building on a strong community identity and developing the community asset. The service is based a the centre of the community in a Community Centre which has enabled developing contacts with existing groups and activities. The team has initiated a “Community Meal” which has involved local business and other agencies. The first Community Meal, hosted by the team, was attended by 100 people who live and or work in the locality. This initiative is being taken forward and the Community Police service will be the hosts for the second meal with the aim to widen the people attending to include some of the younger community thus establishing a better relationship between age groups and potentially impacting upon anti-social behaviour and the wellbeing of people who live in the area.
Wider Active Support
As well as the direct partnership between NSCHT and Stoke local authority the Care hub project has “pulled on” services from a wide range of providers in the Meir area including:
• Fire Service
• Primary Care – Health visitors Community Matron
• Third Sector – Brighter Futures, Voices Staffordshire Housing (Revival) Changes Wellbeing
• LA Housing
Organisations have been involved in different aspects of the delivery of the model with the Community police service taking an active role in making referrals, supporting care packages and solutions and working to develop community identity. Similarly, the Fire Service, through their preventative agenda are also actively involved.
From the third sector both Changes ( Mental Health and Wellbeing) and Brighter Futures have been actively involved in developing the community offer for the support of the mental wellbeing agenda. In real terms this has meant that people who would not have previously accessed wellbeing support are now doing so.
Co-Production is at the core of the service delivery. Care Co-ordination which reflects the individuals own strengths and goals is a fundamental within NSCHT. Additionally, sharing the use of Wellness Recovery Action Plans across all of the services has heightened the awareness of the persons ownership of what keeps them well. The team works to the principles of cooperative working:
• Listen to me conversation with the person
• Agree goals, who is doing what and
• Focus on solutions
The person is involved throughout and outcomes are agreed.
Looking Back/Challenges Faced
The change process across health and social care throughout the UK is complex with transformation of the service model being driven by national policy, economic necessity and local demand.
The Meir Care Hub is one aspect of a wider MCP development agenda across North Staffordshire and Stoke on Trent. This has been both a benefit and a challenge. From a positive perspective the principles and goals are agreed and established within the wider health economy and the Care Hub Team model supports the wider development. The relationship between organisations is generally good within the expected strains of sometimes conflicting pressures on budgets and services.
The original aim was to start with a controlled and limited target group to test out the concept and give team time to develop but the demand on the service has been significantly higher and the service has had to adapt to the change. From a local authority Wellbeing Team perspective this has been relatively straight forward as they are essentially working with what would have been their existing caseload. In mental health the work has been new and in many cases in additional too existing work. The allocation of resources to the service has had to come from the current service budget whilst maintaining the existing contracted service delivery. Had the service been fully staffed from the start the impact would have been greater. However, the new model has not had a negative impact on the budget of either of the organisations beyond the limited start-up costs for equipment and this has helped the model gaining support within the “political” agenda.
The ability to go with a wider geographical area and cover more teams would have been better as this would have reduced the need to run two models covering the same service.
The model is essentially sustainable within current budget allocation and evidence supports the strength of locality based services working together. Sustainability is now a political and organisational decision with different considerations for both the local authority and NSCHT.
However, the closer working relationships are now well established and are not solely dependent upon organisational change. The awareness and introduction of third sector services in the area is established. The project has been extended for a further three months whilst these decisions are made.
Evaluation (Peer or Academic)
Internal evaluation has been ongoing and internally the team has undertaken weekly reflective development sessions. Data on the work undertaken has been collected and the model is part of a commissioned evaluation being currently undertaken by Sheffield Hallam University.
As outlined above initial data shows that the time spent reaching a outcome for the person in the service has been reduced. This has also indicated that where a individual needs a range of services these are being accessed more quickly and the involvement is coordinated. People with complex needs get a comprehensive response which address the presenting issue as well as looking at the wider causes and implications without the need to repeat their story for further referral and assessment.
Anecdotally, people using the service are happy with the service they receive.
From a professional perspective the frustrations of assessment/referral culture have been reduced and workers feel able to follow the person through to an agreed outcome.
Both the professionals directly involved in the service and those in the wider circle report positively on the new approach.
The project reports back into the North Staffordshire MCP development structure and the MCP Locality Group.
It is also recognised within the Co Operative Working Board within Stoke which has representation from statutory and third sector senior managers.
As the model develops the outcomes will continue be shared.