Local Community Networks Reimagining and shaping a new

Local Community Networks Re-imagining and shaping a new health and well being landscape Tina Favier Coastal Care

The context for Coastal Care ”A radical shift in the way the NHS organises it’s services” “Coastal Care” is a newly forming partnership of those leaders and. organisations that collectively commission and provide health and care services in Coastal West Sussex has a population of more than 500, 000 living in coastal towns and rural villages in the central south coast of England. Coastal West Sussex Clinical Commissioning Group 48 General Practices in Coastal West Sussex County Council District and Borough Councils Sussex Community NHS Foundation Trust Sussex Partnership NHS Foundation Trust Western Sussex Hospitals NHS Foundation Trust Sustainability Transformation Plans (STPs) STPs are five-year plans covering all aspects of NHS spending in England reflect: …a shift in the way NHS services are organised, premised on collaboration, rather than competition. …a response to the challenges facing their local services through ‘place-based planning’, collaboration with other services and sectors to improve population health and wellbeing … a growing consensus for more integrated models of care to meet the changing needs of the population whilst addressing thegrowing financial problems y providers managing the collective resources available for NHS services for their local population. …quality and new models of care; improving health and wellbeing; and improving efficiency of services All 44 STPs are now published and publicly available. From April 2017, they will become the single route to access all NHS transformation funding

The case for change In Coastal we knew that the public and patients receive largely good or excellent care, when they reach the required service. But, they feel frustrated by: - Their inability to access the system appropriately, and - by the breakdown in links between parts of the service. Coastal West Sussex has one of the oldest populations in the country, with more than 25% aged over 65, and more people aged over 80 than most other areas in the UK. Coastal West Sussex is a historically high performing health and social care system, with services delivered by stable and robust organisations and with a track record of partnership working. However, a number of trends mean that health and care services in Coastal West Sussex are not sustainable in their current form.

Our vision for Accountable Care Early and supporting self-care - reactive to proactive. Organising care with communities and partners around care. Breaking organisational boundaries to create collaborative systems for population health and smoother/ integrated care pathways. A whole population approach to health or care need; generalist or specialist, physical or mental, adult or child. Aligning around a common purpose, a single set

Building a new ambition for Coastal In Coastal we knew that the public and patients receive largely good or excellent care, when they reach the required service. But, they feel frustrated by: - Their inability to access the system appropriately, and - by the breakdown in links between parts of the service. The Clinical Commissioning Group, with NHS providers and local authority partners developed a shared plan for Coastal West Sussex ‘Coastal Care: Inspiring Healthier Communities Together’. This plan sets a new and bold ambition to work differently and transform our services around our people and local communities, introducing a new model of care focusing on: better outcomes for people, reducing costs and developing a more sustainable workforce The Marmot Review (2010) emphasises that 70% of a persons health is significantly influenced by social and economic factors along with the environment and a persons family. We need to harness and used all of our powers to influence these issues.

The Coastal Care model

Local Community Networks …the building blocks of the new Model of Care Eight Local Community Networks have begun to form across Coastal, with an ambition to organise the provision of health, care and support services around the needs and assets in their communities: One Plan: One team: One set of shared priorities LCNs will need to: Each LCN will have an MD Team, centred around people, moving towards One Plan, One budget, One set of shared priorities Be ambitious and challenge themselves to integrate teams around local people’s needs Shift a largely reactive workforce to a more preventative, proactive and local one; New relationships, alliances and ways of working Collaborate with a greater range of providers, including the voluntary sector, and local people, and change the nature of the conversation; Improving health outcomes and a positive value for local people/communities. Foster real change and innovation More creative and ambitious solutions for their localities. Work with communities to rethink health and community services

CWS Local Community Networks and their Combined Practice Populations Rural North Chichester – 36, 931 Chanctonbury – 46, 581 LCN lead GP – Dr Emma Woodcock LCN Lead GP – Gordana Ninkovic. Chapman & Karen Crawford-Clarke Practices : Loxwood, Petworth, Pulborough Riverbank Practices & Senior Partner Billingshurst , Henfield Glebe, Steyning North Downs Chichester CHAMP – 84, 738 Chanctonbury LCN Lead GP – Dr Andy Pullen Practices : Cathedral, Langley House, Lavant Road, Parklands, Southbourne, Tangmere, Witterings, Selsey CHAMP LCN Lead GP – Dr Mark Halloran WHAT Regis Adur Arun Adur – 64, 234 CIC Practices & Senior Partner: Ball Tree, Harbour View Kingfisher, Manor, New Pond Row, Northbourne, Orchard Regis Healthcare – 96, 769 Arun Primary Care – 61, 597 Cissbury Integrated Care – 46, 368 LCN Lead GP – Dr Bruce Allan Practices : LCN Lead GPs – Dr Glyn Williams & Dr Mark Lee Bersted Green; Bognor Grove House, Maywood, Arundel, Avisford, Croft, Flansham Park, West Meads Practices Coppice, Fitzalan, The Lawns, Park Surgery, Westcourt Willow Green LCN Lead GPs Dr James Bramall & Dr Mike Jenkins Practices Worthing Medical Group Seldon Road The Strand Worthing Health Alliance Team (WHAT) – 72, 231 LCN Lead GP – David Stokes Practices & Senior Partner: The Barn, Broadwater, Lime Tree, Phoenix St Lawrence, Victoria Road

A new type of leadership for LCNs Traditional leadership is not enough to lead in complex systems LCNs will require great and ambitious teams, strong governance for decision making to challenge themselves to use resources in more creative and innovative ways for their local communities. They will also need to develop health care and provision through dispersed networks, to grow capability and capacity and harness the great networks and strengths in communities LCNs will require strong leadership for their place (as opposed to organisation). And skills and behaviours including: Convening others– uses their interpersonal skills to build alliances and networks, collaborate and develop strong relationships; Working through complexity and manage uncertainty and ambiguity, setting out the next step and way through Creative thinking –designing services around individuals and their journeys Iterative planning – is able to start somewhere, learn adapt and learn; Reflective and learning, focusing on how as much as the doing; Challenging and questioning – able to shifting stuck thinking and work through issues effectively Whilst Development Managers will organise and hold collective efforts, an OD programme will be essential to help develop individual leader skills across three areas: Cognitive - thinking systemically, handling complexity, judgement in ambiguity; Personal - self management and resilience, reflective learning awareness of own patterns; Interpersonal - multiple perspective taking, empathy, flexibility of style.

A population based approach Work is underway to develop some strategic pieces of work across all LCNs on: Older People; Urgent Care; and Social Prescribing. Each LCN will be expected to deliver against these priorities, but how these are delivered will vary and be adapted according to the local population

Older people and more integrated care …adopting wellness, prevention and integrated care principles (The Kings Fund) Our ambition is to develop a more integrated and improved service for our most vulnerable patients. We want to develop an integrated approach (see below) that is more effectively focused on people who are frail, at the end of life, with dementia and in nursing homes. Current services are disjointed and we think we can do better. We want to create an ethos of ‘one patient, one team, one record, one care plan’. Our aspiration is to make sure that our most vulnerable patients benefit from high quality care, including falls prevention and other key interventions. “For every 10 days spent in hospital, a person loses the equivalent of 10 years in muscle loss” Dr David Hunt Audit of A&E for Older People Identified a significant no were living alone, with 18% in a Care/Nursing Home Over half had signs of Dementia, by 50% were undiagnosed Issues with Falls preceding the admission, and care plan information to assist Hospital staff Opportunities from this now being taken forward under the Urgent Care Group (June 2017) The Kings Fund

Social Prescribing …the art of connecting with people (their issues, needs and assets) and connecting them into local services, support and communities. Social Prescribing is provided through different models, but at it’s core is an integrated service that connects people to services and communities. Social prescribing is: - integrated and embedded as part of health (GP or Hospital – or both) and the voluntary sector/councils/communities; - Staffed by known and trusted individuals that manage referrals from health, ensuring a good flow of information back to health to assist with learning about individual cases; - works with individuals in a holistic way over a number of occasions (if needed), to understand address needs/issues in the right priority order – cutting through red tape; - Led by staff who are relentless in their pursuit of “doing the right thing” for people and who are utterly pragmatic; - Connecting (and physically taking people if needed) people to services and community activity to support and help them. One of the High Impact Actions – Chapter 2 Five Year Forward View …a strategic approach to the relationship with the voluntary and community sector. Adur and Worthing Going Local: 3 Community Referrers + 300 cases since Nov 16 Achieving great results for local people. Well respected by local GPs

LCNs: getting going… • 8 LCN “Initiation” meetings, commenced in March • Relationship forming - Health Care providers and commissioners came together (GPs, CCG, Mental Health, Community Nurses, Hospitals, Councils and some Voluntary Sector) for the first time • Emerging priorities – high level data introduced, exploring how the system feels, shared priorities • Building a picture of the local patch – local assets and relationships • Focus is on… • • the need to involve others Take the first steps, first priority… Secure resource to enable activity – Development Manager Develop the culture, skills and behaviours

South Cissbury LCN (Worthing, south of the railway line) First priority: Older people Focusing on working on integrated working At a glance (and in comparison to the others) we know this LCN has : One of the most challenged and complex populations with relatively young populations and highest ethnic mix Deprivation, child poverty, lone pensioners High levels of obesity, binge drinking, self harm Highest levels of self harm of YP in the area along with Adur Golden moment: Desire to develop an integrated approach to vulnerable older people, beginning with the development of a new Multi. Disciplinary Team and also focused on addressing the issues older people face in terms of being discharged from Hospital discharge: Two GPs and a Hospital Geriatrician led a piece of work to assess Hospital discharge, which demonstrated that many being fit but not being discharged into the community Integrated Team: Work has begun on developing an MDT Team event to build relationships and redesign how they work together. Now integrated with Community Nurses, Community Matrons and District Nurses. Governance for the work now in place Hospital activity dementia and Mental Health issues Highest number of care homes in the county Some overcrowded housing Network event being planned with the voluntary sector to understand local services As a major charity in the area, Guildcare shared the breadth of their community based services for older people with the GPs and Health partners… Home from hospital services, practical help, advice, promoting physical and mental wellbeing, and connecting older people to reduce isolation Quick wins have been made: - Improved services around catheters through a clinic introduced at Selden; - Changing and speeding up practice around wound dressings; - Reorganising weekend services Practice Group Lead

North Cissbury LCN (Worthing, north of the railway line) At a glance (and in comparison to the others) we know this LCN has: First priority: Young People and Mental Health This LCN with Adur have significantly more issues around self harm and young people. Desire to explore this and develop community based solutions. Second priority: Older People and more integrated working Desire to develop a more integrated approach to older people in the community. Similar to South Cissbury Good levels of patient feedback for GP services Prevalence high for depression and dementia Pockets of Deprivation Relatively young but older than the national picture Integrated Team: An ambition to take this forward and work to be planned. Development of Salvington Lodge community beds also being considered. More work to be planned Golden moment: The breadth of services – commissioners, GPs, Practice Managers, providers, voluntary sector, educators, councils and others. . Coming together to develop a shared ambition for good mental health Highest levels of self harm of YP in the area along with Adur 6 GP Practices – across Worthing, have experienced a merger and practice closure in past 2 years. “I was inspired by the initial LCN meeting to take up the work on YP”

Adur LCN At a glance (and in comparison to the others) we know this LCN has: One of the youngest populations wsith more under 16 s First priority: Young People and Mental Health This LCN with N. Cissbury have significantly more issues around self harm and young people. Desire to explore this and develop community based solutions. Second priority: Older People and more integrated working Concern around older people, loneliness and isolation and a desire to work on connectedness and the development of networks Lowest development of aged 5 s and GCSE attainment Work underway to explore the issues around older people using the expertise and knowledge from Guildcare and others Poor childhood obesity and hospital admissions for children of all ages Highest levels of self harm of YP in the area along with Adur Poor levels of central heating anf high levels of lone pensioners Obese adults and health eating High premature death for cancer under 75 Years High prevalence of cancer, dementia and depression Our Patient Representative challenged the LCN to remember to design around the needs of its local communities. Connecting moments These LCNs have been convened in a local high School, changing the nature of the conversations and dynamic. Links between education and health are really emerging. Young People and Community-Based approaches to Mental Health

Arun LCN Met 3 times At a glance (and in comparison to the others) we know this LCN has: Lower rate of Age 5 and GCSE attainment Higher number of lone pensioners Poorer children’s weight indicators Poor rates of hospital admissions for injury aged 1524 First priority: Older people Second priority: Prevention Focusing on working on integrated Desire to develop a more integrated approach to older people in the community, particularly given the number of lone pensioners and number of care homes in the area. Public Health have provided an overview of issues and options for the local population. More work to be carried out. Issues raised around self harm and young people Care Homes forum Forums with local care home managers/lead clinicians are being re-established to provide a networking and an opportunity to share learning, as well as disseminate consistent messages to care home staff in the area. Integrated team People living in nursing homes will benefit from increased support from a newly formed integrated team to receive key interventions such as improved quality care plans, medicines optimisation & falls prevention assessments. More obese adults and low levels of healthy eating Nurse, SCFT . Priority 1: Older people High levels of self harm and alcohol Higher levels of premature death Whole population approaches working and working with care homes “Services don’t always communicate effectively with each other, leading to duplication and people falling through the cracks. ” Education & training program Aligning one GP to each Care Home Aims to improve relationships between General Practice and local care homes , to improve efficiency and reduce duplication. General practice , SCFT, WSCC & WSHFT have developed a 12 month education and training program for care home staff. This will be delivered by partners to increase care home staff competence and confidence in a number of key areas. Great to see a local School Head involved, along with Public Health, a Patient Representative, Mind, VAAC, Age UK…

Regis LCN At a glance (and in comparison to the others) we know this LCN has One of the most challenged older and complex populations Poor age 5 and GCSE attainment Some overcrowded households First priority: Older people Focusing on working on integrated working Desire to develop an integrated approach to vulnerable older people, beginning with the development of a new Multi. Disciplinary Team and also focused on working with care homes to improve their prevention and care of their older people. Test and Learn work programmes being developed: Managing UTIs better; Falls Prevention work; Catheter care Managing dressings better Hospital activity around harm and injury high “They are such a critical part of the local system” 2 Paramedics now based in the LCN team. Clinical supervision being provided for the Paramedics now as part of the LCN along with training and an education programme “Test and Learn” Reducing demand from care homes on the system Worse levels of obesity in children and hospital admissions for children all ages Issues around healthy lifestyles adults Role of Paramedics: Care Homes Developing relationships with the Care Homes and working with them to begin to develop their skills to manage more effectively. “Education event held which was excellent” Hospital Discharge Review To understand the flow of patients in and out of hospital to inform the project. Demonstrated that many don’t need to be there and the stepping up of the role of others to reduce those going into and coming out of hospital “It takes a few meetings to get to the point where you can trust people. We do this with other GPs but not others… we just don’t normally behave like that” GP Developing relationships and the Multi. Disciplinary Team (Primary Care, Geriatrician, PMs and SCFT) “Paramedics are such a critical part of the system but we have not involved them before” Practice Group Lead

Rural Chichester North LCN At a glance (and in comparison to the others) we know this LCN has: The least challenged population First priority: Older people Focusing on developing a community support strategy for older people Desire the develop more holistic and integrated care and community support for older people, particularly around social isolation. An older population with fewer under 85 and more under 16 years Poor development age 5 and GCSE attainment Poor levels of central heating but fewer lone pensioners Less obese adults and more healthy eating Hospital admission for younger age for harm higher. CHD, Stroke, Cancer and CKD higher. Social Prescribing Work has begun to explore the development of Social Prescribing for the LCN. Workshops are being planned with Patient Rep Groups, GPs and stakeholders to develop the focus The District and WS Communities Teams are working with this LCN to picture build and develop the networks. Did you know? A recent research review of Parish Council potential Health and Wellbeing roles has been completed.

Chichester LCN First priority: Older people At a glance (and in comparison to the others) we know this LCN has: Challenged with one of the highest numbers of over 85 Yos and under 24 Yos Isoated deprivation, child and fuel poverty Childhood obesity Lone pensioners Focusing on developing a community support strategy for older people Desire the develop more holistic and integrated care and community support for older people, particularly around social isolation. Exploration of the priority: Age UK, Councils and GPs to lead an interactive session to determine the issues and priority around older people to ensure wider involvement and engagement from local services Second priority: Children Obesity and healthy weight Pockets of issues identified in one of the local areas. Work to be scoped around this next. . . The newly formed IPEH (WSCC) and District Council will explore the issue of healthy weight and children and potential next steps… Golden moment: Age UK shared the breadth of their services in the local area around practical support and advice and home from hospital schemes. Age UK are now leading the exploration of work on older people… Lowest levels of age 5 development One of highest levels of hospital admissions for harm and injury across all ages High prevalence of dementia Integrated Team: Work is also being planned to develop a Multi-Disciplinary Team “An exciting time for the health and wellbeing of Chichester, with new partnerships between health, social and voluntary sectors” GP Lead

Chanctonbury LCN First priority: Older people Focusing on developing a community support strategy for older people At a glance (and in comparison to the others) we know this LCN has: Older population Concern about larger proportion of older people and issues around access to services. Desire to encourage and find ways of improving personal independence of older people and improve health and wellbeing Better development at age 5 and GCSE attainment Central heating and lone pensioners Chidren’s weight and higher hospital admissions (except 1524) Less obese adults and more healthy eating Building the Networks from the bottom-up 4 natural geographies- Steyning, Storrington, Billingshurst and Henfield Starting bottom up the desire it to find and work with local groups and services to develop better support and indoendence for older people. Lower hospital activity Local groups involved MIND, Age UK, Parkinsons, Impact Initiatives… Second priority: Children Obesity and healthy weight Pockets of issues identified in one of the local areas. Work to be scoped around this next. . . The Haven’s Community Brainstorm Event June 15 th An event to explore community involvement and ways clubs can reach out to help the most vulnerable. The lead GP for the area, Karen, is a real connector and has been busy building networks and connections with local groups to help collaborate.

Question? What are the challenges and opportunities for the voluntary sector to engage with this work?