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Well Connected Health & Wellbeing VCS Sub Group
VCS Integration with the Well Connected Initiative
Report and Recommendations
June 2014
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CONTENTS
Page
Introduction 4 Process 4 Summary 5 The VCS Perspective of the Well Connected Initiative 7 The VCS and Health and Social Care 13 Defining the Circles of Care and Understanding their Relationship 18 VCS Engagement with the Well Connected Initiative 27 The Worcestershire VCS Value to the Well Connected Initiative 29 Investment in Wellbeing to Achieve the Vision 31 Recommendations 34 Conclusion 35 Appendices 37
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Introduction At the Well Connected (WC) Pioneer visioning event in February Philip Talbot, from Age UK Herefordshire & Worcestershire (Age UK H&W) undertook an action to engage with key Voluntary and Community Sector (VCS) organisations to develop the vision, opportunity and value contribution the VCS could make to the Well Connected initiative to achieve its outcomes. The report will be presented to the WC Strategic Partnership Group (SPG) for consideration that its content be noted and recommendations implemented where appropriate. It is intended that following consideration by the SPG, it will be available to the wider VCS movement.
Process The group (H&WBSG) was selected from six key Worcestershire based voluntary and community sector communities. Age UK H&W; Fortis Living; Community First; St Richards Hospice; On-side Advocacy and the Worcestershire Association of Carers. (Appendix 1) The group was formed as a representative selection of interested organisations with a range of links to wider VCS groups and bodies such as Worcestershire Voices; OPVSSN; OPCG; Older Peoples Forums; Housing Associations and specialist disability groups. The group reviewed the overall task following a briefing with Frances Martin the Programme Director of the Well Connected initiative. All had been involved in some way with the development of the Social Impact Bond (SIB) work undertaken by WCC and Age UK H&W at an earlier date. The group has agreed to achieve the objective in five steps: 1) To develop a VCS perspective of the Well Connected vision to enable the VCS to better
understand the objectives and provide a more holistic understanding for the SPG 2) To map the role of the VCS within the care model and offer suggestions which help
evolve the model for Worcestershire 3) To gain a wider comprehension by all of the existing and prospective role of the VCS in
the process and thus enable the wider VCS to contribute effectively to the initiative. 4) To establish a programme of ‘buy in’ by the VCS (and WC partners) to ensure the WC
vision and objectives are adopted and implemented. 5) To make specific recommendations on the central role the VCS can play and where
investment is likely to be the most valuable, to achieve the outcome vision of the WC initiative
The group used local, national and international research and evidence to inform the process, formulating the recommendations through a programme of interactive workshops. (Appendix 2)
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Summary The VCS group (H&WBSG) worked cohesively to achieve a positive assessment of the Well
Connected programme. They recognised that the initiative was a ‘first step’ in developing an
integrated health and social care environment which should recognise the value and
contribution the VCS could make to the whole initiative.
The group firmly supported the focus of the WC initiative in putting the individual at the
centre of this initiative, recognising that they had a primary say in what was done for them,
but that they also had to take greater responsibility for their own health and social care if we
were to improve all the services affected.
The group felt its comments on the principles and outcomes would enhance the initiative and
enable the VCS to share the overall commitment required to achieve the 2020 vision.
The group recognised that this programme represented challenges for the VCS. The building
of integrated relationships to deliver better services would require some significant ‘shifts’ in
thinking, attitude and action.
The group also highlighted the need for the statutory sector to think differently about the
relationship with the key VCS organisations who deliver effective solutions to the wellbeing of
people in communities at an early stage in the provision of support needed. Highlighted in
the report is a model which illustrates how an integrated approach can achieve the outcomes
desired.
The group recognised the need to provide a new level of support for clients and makes
recommendations that will take account of online provision of information, guidance and
advice.
The Circles of Care model, which highlight some key areas of segmentation, were generally
felt to be beneficial to analysing issues and developing solutions. The group, and the wider
VCS movement, contributed to their solutions already but they felt more could be done and a
further focus on integrated effective solutions would be beneficial.
The group spent time analysing the Circles of Care and outlining areas where further work
might enhance the integrated decision making. This work required further investment.
The group highlighted the value of utilising the ‘trusted’ provider within the VCS. They also
recognised the need for encompassing specialist VCS support providers to ensure the needs of
the most vulnerable were accommodated at an early stage.
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The group also recognised the need for cost effective solutions for integration and the need to
ensure the all parties understood and focussed upon this issue.
The VCS has a wealth of experience within its ‘congregation’ including service users and the
wider public engagement groups who could be used in the co-design of services. The need to
address a new commissioning approach was obvious and the group were ready to work on
this with others as appropriate.
The VCS could also mobilise and manage a volunteering service in support of integrated care,
adding significant value to the initiative, but that it needed proper investment.
The group highlighted that investment in the whole system should be considered. It was not
just state related investment that mattered. There were an increasing number of additional
sources of funding available which could enhance the offer to the public and achieve better
outcomes. These needed to be considered and harnessed.
The group put together a series of recommendations for consideration, some of which
required simple action and others investment.
The group felt that this was a good ‘first step’ in the process, but that new ways of thinking needed to be accepted and key issues needed to be addressed to enable the transformational change initiative to happen and enable the VCS to contribute fully and be part of the solution.
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1) The VCS perspective of the Well Connected Initiative 1.1 Critique of the Aims and Objectives
The group considered the strategic narrative, principles, outcomes and commitment of the initiative and made a number of observations. The following is a summary of the feedback from the group for consideration.
The National Voices narrative;
“You plan your care with people who worktogether with you to understand you and yourneeds, allow you control and co-ordinate anddeliver services that support you to achieve theoutcomes important to you”.
1. Definition of care is needed (care in the broadest sense not just from a health & social care perspective) – does early intervention and prevention need to be added to give a complete picture?
2. Should this be an ‘I’ statement? Whilst recognising that the SPG considered the actual change in wording, the group felt that the use of the personal ‘I’ statement was more powerful. For example, “My care is planned with people who work together to understand me and my carer(s), put me in control, co-ordinate and deliver services to achieve my best outcomes”. This statement is supported by an organisational statement from National Voices, “Co-ordinated care means…partnering with the person to plan, pick and pull together care, support and treatment” It would avoid the interpretation below (3)!
3. The statement using ‘you’ suggests a lack of buy-in to the ‘I’ statements? The group did not feel that this was the case, but the language was important.
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Our agreed principles
• Improves the overall quality of care that an individual experiences.
• Identifies and addresses an individual's needs in a whole-person approach
• Offers more care in community hospitals, the wider community and in
people’s homes rather than in acute hospitals
• Create the capacity in the acute hospital to allow them to maximise
specialist skills for those who need it
• Invests in prediction, prevention, early intervention and out of hospital
services
• Joins up services across organisations and across care settings
• Adopts evidence based pathways
• Encourages individuals to take responsibility
1. Wider definition of care is needed for the first principal and should include carers and family. Right care, right quality, right time. Need to illustrate “Doing with” not “doing to” imagery. Need to add “choice” for individuals.
2. Principal two agreed 3. Is Principal three an objective or action? Perhaps it should incorporate ‘right care in
the right setting’ or the full spectrum of community settings eg: Community Hospitals, GPs, community care etc.
4. Is Principal four is an objective or action? 5. Principal five agreed 6. Principal six – “Co-ordinates services across sectors, organisations and care settings? 7. Principal seven – what does this mean and in what context? Is this anti-innovation? 8. Principal eight – “Empowers individuals to take responsibility for their health &
wellbeing” 9. Does innovation, development and value for money need to be included as principals? 10. Jargon needs to be limited in order that everyone can understand 11. There is no reference to doing things in a safe manner. A safeguarding principal
statement might be appropriate.
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Our agreed outcomes
• Improved access to services that support people in looking after themselves
and each other.
• Access to all relevant patient and service user information for all those
delivering services to an individual
• Reducing hospital admissions and hospital length of stay by all those
delivering services working to keep people independent and at home where
possible
• Access to acute hospital care is swift and focussed when needed
• The experience of the overall care and services that individuals receive is
improved
• Better overall value for money
1. The outcomes should map to the 2020 vision/commitment statement – not all of them currently do so
2. These outcomes perhaps need to be SMART tested 3. Outcome one – More people looking after themselves and each other through
improved access to information, advice and self-help 4. Outcome two – A linked patient and service user information system for all partners 5. Outcome three – Reduced hospital admissions and hospital length of stay 6. Outcome four – More effective and appropriate acute hospital care – more
clarification is needed on this outcome 7. Outcome five – This is about patient experience, should the ‘I’ statements be referred
to here? 8. Outcome six – we think this should move to the Principals 9. Outcome seven – Services are equitable and meet the needs and demands of
individuals 10. Outcome eight – The group felt that an additional outcome should talk about
improving or balancing capacity across the whole system. This raises questions and focuses attention to where the WC initiative can work better. For example, should care homes and the NHS personalisation agenda be included and referenced in the outcomes? How much independence would an individual get to spend their budget? What would be the impact on personalisation of improved choice? How does the Well Connected programme work with the Health & Social Care personalisation agendas, including personal health budgets?
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We agreed that our shared commitment is that in Worcestershire
by 2020…
• Individuals, families and communities will be supported in taking control of their on going health
and wellbeing and in looking after themselves and each other so that by 2020 those over 65 are
living as healthy lives as possible.
• All people over 65 or those under 65 living with long term conditions or complex needs, will have
their own personalised ‘joined up’ care plan where the priorities set by the individual are
supported by the care that they receive.
• The plan will be ‘owned’ by the individual and supported where needed by a member of their
family or someone acting as a care coordinator under the auspices of their GP team.
• The person and everyone involved in providing care and support will be able to access and
contribute to the individual’s care plan.
• If a person needs specialist care, their GP will share responsibility for their care with their named
consultant and, with help from integrated community teams and community support, will facilitate
their return home as soon as possible.
1. Commitment one – agreed 2. Commitment two – The group suggests a revised commitment as follows: 3. “all people over 65 or those under 65 living with long term conditions or complex
needs, will have their own personalised co-ordinated care plan where the priorities and preferences set by the individual are supported by the care that they receive”
4. Commitment three – The plan will be owned by the individual and supported where needed. This needs clarifying and underpinning with a principal
5. Commitment four – agreed 6. Commitment five – the group felt this focuses too much on health (community teams
and support) – the group felt it needs to be expanded. More clarity also is needed about where is the GP vision/principals link. The commitment needs to be more inclusive of other sub sets of care as “support” may be provided from a number of areas not just statutory health providers.
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1.2 Comment on re-naming of the circles of care The group (H&WBSG) felt that the ‘circles of care’ could be re-named and re-coloured. Silver would be a better ‘Healthy Living and Wellbeing’ circle colour with green being a good colour for the re-named ‘Regaining and Maintaining Independence’ circle. By implication the red circle would become the newly named ‘Proactive and Reactive Care’ circle. It was also felt that whilst recognising the national link to Discharge to Assess, it would be more appropriate to re-name this circle which should define Discharge itself and therefore the circle name should reflect this.
1.3 Contribution by the VCS H&WB Sub Group
The group has invested significant resource in developing and understanding its role in relation to the Well Connected initiative. It recognises, however, that this is just a first step.
Establishing a fully integrated view of the health, care and wellbeing of an individual served by the parties involved, is a fundamental step. Beyond this are the practical implications in real situations that deliver a better experience for the patient/client whenever and wherever they access the system.
1.4 Challenges for the VCS Building integrated relationships which deliver the most appropriate mix of support services will take time and requires some parties to adapt and improve their behaviours and in some cases their performance levels. There is recognition that this will be easier for some than others and that there may well be some ‘casualties’ as a result. The group was clear that its remit was to highlight a generic development process for the VCS within the Well Connected initiative.
Healthy living and wellbeing
Proactive and
Reactive care
Crisis intervention, admissions avoidance
Bedded care
Discharge to assess and Discharge
Regaining and
Maintaining independence
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1.5 Challenges from the VCS The investment in the initiative has to be proportionate by the statutory sector. There is a clear desire to ‘shift’ the demand by patients and clients from the intensive medical intervention programmes to less intensive, sometimes non clinical, healthy living interventions which provide better planned management of people in care and health environments. How will realistic investment be achieved?
The group also highlighted that the risks are different from the traditional ones we currently experience daily in our various environments. They pose unfamiliar challenges for many people. How will these risks be defined and who will be responsible for making the decisions relating to these new risks?
1.6 Conclusions
Working effectively with the VCS offers all the players the best chance of successfully achieving the cost saving programmes being considered and the more important, demand transformational change requirements necessary, to make the aim of improving the health and wellbeing of older people in our communities, a success. The group believed the VCS was ready to respond to the challenge and work collaboratively. We recognised the need for an alliance of willing and able VCS partners to achieve the overall aims. The group hope the SPG will consider implementing the recommendations highlighted in this report.
The group seeks a remit to interpret the strategic vision, as indicated in the report, to make it more relevant for the VCS when cascading into their organisations and the wider VCS network.
The group was conscious that resources were limited and that achieving such transformational change would not be easy. It was clear that there needed to be the appropriate resource channelled into the prevention, early intervention and post intervention programmes for there to be any chance of success to be achieved. The group also felt that success would not be achieved overnight, particularly where change in demand was expected to be significant and that the best way forward was to achieve incremental change with timescales being managed appropriately.
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2) The VCS and Health and Social Care 2.1 Overview:
The group considered the VCS role and interaction at a strategic level. The group felt the traditional two circle Venn Diagram model needed developing. The group also analysed the ‘circles of care’ adopted by the Well Connected initiative, focussing upon the Healthy Living and Wellbeing (silver) circle; the Maintaining Independence (green) circle; the Proactive and Reactive core (red) circle and the Care and Discharge Pathway from the orange circle.
2.2 The ‘Boxed Venn Diagram’ Model Illustration: (Figure 1) Whilst recognising the simplicity of the illustration, the group agreed that
developing this model and understanding the fundamental relationship between the three areas of care was key to a full engagement with, and success of, the Well Connected initiative.
The revised model would therefore be interpreted as follows:
Where: A = Wellbeing care, B = Social care, C = Health care D, E, F, and G are areas of interaction defined through the Well Connected initiative. They represent ‘work’ in the ‘circles of care’ Wellbeing Care being defined essentially as Prevention and Early Intervention services in the community, many of which are independent of state intervention. The blue and red ‘people’ represent ‘well’ and ‘ill’ people respectively.
A
BC
D E
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The model establishes a ‘new’ dimension to the care of people in communities and recognises the significant contribution made by the provision of less formal care in the community. The group felt that the recognition of this approach was fundamental to being able to work on an integrated care initiative which relied on all the partners working more effectively together.
2.3 The Client Journey
The group considered a number of individual scenarios of people requiring help and support across the care spectrum. Using three of the circles of care, the group illustrated the ‘journey’ and needs of an individual. All of these individuals were seen to have similar generic needs but also individual specific needs. The illustration below highlights the flow, or patient/client pathway and likely interaction requirements. Figure 2 illustrates this ‘journey’.
Healthy living and wellbeing
Proactive and Reactive care
Regaining and Maintaining
independence
Guidance
Assessment
AdviceWellbeing Care Plan
Health, Social Care or Wellbeing ‘Incident’
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The ‘journey’ is a typical illustration for all four major intervention streams. (Wellbeing Care; Primary Care; Secondary Care and Social Care) What differs is the short term outputs which are dependent upon the needs of the client. They are also not mutually exclusive and can be, and sometimes are, interlinked. There is also clear evidence of the value of interlinking with the use of social prescribing. It should be recognised that by including Wellbeing care in any overall care model it may add a degree of complexity, but its value is in the significant reduction in demand that can be achieved by linking interventions with reductions in demand throughout the system. Good examples of this are the Carers Wellcheck, the Wellcheck service and Advanced Care Planning in the community.
2.4 Support for the patient/client (p/c) Throughout the whole process, it was recognised that a fundamental task of everyone concerned was to communicate more effectively. There is a significant piece of work required to consider how we all communicate better internally with our own organisations; externally with other organisations and significantly how we individually and collectively communicate with our clients. In addition we recognised that in some cases the client’s needs included the provision of someone to help them through the systems they are faced with when they have a health or wellbeing incident. The value and provision of advocacy is well documented elsewhere and has become an accepted support service across the provision of health and social care services. Clearly there is an issue about proper investment and the group believes no-one should be disadvantaged when assessing the system. A more recent innovation is the Care Navigator whilst the advocate is someone who represents the views of the client, the care navigator is someone who guides a client through the complex world of health and care on a temporary basis until such a time when they can regain their independence. The role comes in many guises and requires significant knowledge and skill, and is only necessary to support some clients who do not have any other appropriate support. The role can be undertaken by volunteers or paid staff, and possible a mixture of both. This model is one currently adopted by the Cornwall Pioneer integrated care group.
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2.5 Client Segmentation Segmentation by demand: The VCS group looked at the client groups defined broadly by the Kaiser Triangle model (Figure 1). Our view was that the group at the top were sufficiently well identified and interventions would need to focus on better ways of delivering and satisfying ‘ladders’ for clients to access the Regaining and Maintaining Independence (silver) circles and the Discharge Pathway circle (orange).
Those in the second segment and those in the third segment were more
randomly likely to increase demand.
To achieve demand reduction, the group believes there needs to be a greater emphasis on investment in managing the demand in the ‘at risk’ group (second tier).
Figure 3:
The group believes that there are a number of ways in which the clients in the second tier can be identified and engaged with including health and social care VCS data interrogation and direct interface. Segmentation by Condition An alternative approach may be to consider segmenting the population by the relevant condition, or combination of conditions that they have. This would be a less random intervention base to work from and would be enabled by some analysis of the most demanding conditions encountered. The group felt that an analysis of the most prevalent conditions dealt with by the health and social care system, may well enable a more effective investment in solutions.
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2.6 Early Assessment of Need
The group was firmly committed to the view that to achieve a reduction in demand for primary, secondary and statutory social care services there needs to be an ‘early warning’ system in place which enables relatively low cost interventions to be implemented to prevent, or delay, demand on the more costly statutory services and deliver better wellbeing outcomes for clients. An early holistic wellbeing (care) assessment would enable a more effective risk satisfaction system to be considered and would enable prevention and early intervention systems to be optimised to manage demand on the whole health and care system. The group recognises this poses different challenges of the many and varied needs of individuals and the every changing environment that clients live in. The need to regularly review clients, particularly at ‘life changing’ points will therefore be most important.
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3) Defining the Circles of Care and Understanding their Relationship
3.1 Overview The group considered the four relevant circles of care and elements (wedges) within these circles. The group defined the circles in detail and considered how they impacted on the client’s wellbeing. The ‘wedges' covered (Figure 4):
An acceptable definition
The outcomes/outputs which were desirable
Who was involved in the delivery of the outputs/outcomes
What the vision of success looked like
How success could be achieved
What were the risks which caused a ‘snake’ out of the circle
What were the opportunities to facilitate ‘ladders’ out of the circle
Proactive CareOver 65’s and under 65’s with LTC’s / Complex Needs
Definition
Outcomes
Who is involved
Vision ofSuccess
How to achieve it
Snakes
Ladders
Meeting the overallVision, principals,
outcomes
Figure 4 In addition the above information obtained was ‘sense checked’ to ensure it met, or exceeded, the overall vision. Finally, the group identified any other factors which may impact on the circle of care.
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3.2 Health Living and Well Being
Healthy Living and Wellbeing “Over 50’s” (The group included the 50 – 64’s to ensure that this age group had the tools and information to make informed decisions to keep healthy and well into later life) Age Range 2011 Pop Figures 2021 Pop Figures
50-64 115,600 122,700
65+ 92,000 114,300
1. Taken from 2011 Census information, Worcestershire County Council 2. 75+ will increase by 48% 3. 85+ will increase by 49%
The group felt the following points illustrated what Healthy Living and Wellbeing meant to the VCS in Worcestershire:
Definition rom Worcestershire’s Health & Wellbeing Strategy – “Health and well-being is influenced by a range of factors over the course of people’s lives. These factors are related to people’s surroundings and communities as well as their own behaviours. Collectively they have a much greater impact on health and well-being than health and social care services.”
From Health & Wellbeing UK:
Healthy = Absence of Disease
Wellbeing = It is keeping in balance the physical,
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psychological, social, environmental, and economic factors which affect all of us in our busy lives. If one of these areas is out of balance, and disturbed then our overall wellbeing is affected and we need to do something about it.
rom the World Health Organisation “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
Keeping well today, tomorrow and in 10 years’ time
Limited interventions with health & social care
If individuals move into other circles it is for a short period of time and they return back to healthy living and wellbeing
Proactive in own behaviour
Preventing loss of independence
Positive state of mind
Outcomes People cost the state nothing or minimal cost
Access health & social care in a planned manner or only in crisis
Appropriate access to relevant services when needed
Life to years, not years to life
People take responsibility for their health and wellbeing
Creating an environment for community / self-sustainability
The group needs a definition of community and its components eg: locality, shared interest groups etc
Who is involved? VCS – if resourced properly
Providers of Housing
Worcestershire Health & Care Trust
Public Health
GP’s and District Nurses
Total Place eg: planners
Community - Proactive
Private Providers
Individuals
Different levels of engagement would be needed for each group
Vision of success Self-reported wellbeing
People are empowered to make decisions and are proactive
“ eel good” and “what is good” (need vs want)
Healthy life and good death
How to achieve it The group began the work on identifying how to best achieve success in this area
Prevention and Early Intervention Agenda
Community Development (what’s the incentive to make people feel part of their community?) (incentives / encouragement)
Compassionate communities (Paul Cronin Presentation attached)
Information and advice
Things to do to keep people feeling good and healthy
Peer support
Flexible opportunities eg: volunteering, employment, U3A
Feeling valued
Social activities
Self – sustaining
Age appropriate
Appropriate engagement
Create the right environment
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Snakes “Risks to exit” The group considered this area and the impact this may have.
Life transitions (changes in circumstances from where you are eg: accident, things that move you into another circle)
Lack of community capacity
Loss of key person in community
Loss of services and support
Ladders “Opportunities to recover” The group considered how to get people back into the “pink” circle.
Short term interventions to redress the balance
Education
Social prescribing
Suitable services and support
Proportionate engagement
Intensive support when needed eg: Worklessness – is hand holding required?
Understanding environment
Meeting the overall vision
See page 9, Worcestershire Health & Wellbeing Strategy
Other Comments
The group highlighted that appropriate investment would be needed:
I&A
Community Activities
Volunteering
Engagement
Pump prime – sustainability
Evidence, reporting
Marketing
Assisted Death – the group agreed that this should not form part of this work, but a more informed debate would be needed moving forward
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3.3 Regaining and Maintaining Independence
Regaining & Maintaining Independence “65+, with long term conditions and/or complex needs” The group felt the following points illustrated what Maintaining Independence meant to the VCS in Worcestershire:
Definition Living in a safe, appropriate, place of choice with a condition Keeping a condition under control Active in the community Living well with the condition, acceptance of the condition, choice
to manage the condition Maintaining a level of day to day living
“remaining active and contributing to the community, while living either in a private residence or retirement village, alone or with others, and with or without support services” – Ministry of Social Development, New Zealand
Outcomes An integrated care plan, or plans, linked with health & social care is developed
More people understand and live well with their conditions (eg: access to EPP)
Delaying or preventing the demand on social care for at least 3 years
Added value, best value, social value, value for money
Keeping unplanned interventions to a minimum / reducing unplanned interventions
Who is involved? VCS – if resourced properly
Housing
HACW
P’s
Total Place eg: planners
Community volunteers
Private Providers
Vision of success My care and support helps me live the life I want to the best of my ability (National Voices I Statement)
Self-reported wellbeing
Know where to go for services and support
Income allows individuals to maintain independence
Income/resources enables individuals to contribute to their community
How to achieve it The group began the work on identifying how to best achieve success in this area
Access to regular assessment
Information & Advice
Good planning of 3rd age
Ensure service availability
Cross sector communication / co-ordination
Referrals from health, especially P’s, to VCS
Empowerment
Maintaining Independence Plan (part of care plan)
Appropriate developments (See Ageing Well Strategy Map)
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Snakes “Risks to exit” The group considered this area and the impact this may have. It was recognised that each of these points required further analysis and investigation
Internal, external and impact
Location (post code lottery)
Change of circumstances
Loss of services
Resilience to cope
Illness which affects your personal circumstances
Personal to each individual
Spectrum of events happening
Systems
Being defined only by condition
Accessibility of services
Ladders “Opportunities to recover” The group considered how to get people back into the “silver” circle. The value of pro-active as well as re-active work was highlighted.
Change circumstances
Get you better and understand why you are not independent (assessment)
Assessment over and above what is happening in the system – long term solutions
Engagement and communication
Re-establishing independence
Meeting the overall vision
The group recognised the need to continually ensure the initiatives met the overall vision by referring back to the National Voices Narrative
Other Comments
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3.4 Proactive and Reactive Care
Proactive (& Reactive?) Care “Over 65’s, people with long term conditions and more complex needs” The group felt the following points illustrated what Proactive Care meant to the VCS in Worcestershire:
Definition Reactive and proactive care (preventing further deterioration)
Triggers things to happen elsewhere – the integrated pathway of care starts here
Care requirement identified in the green circle but interventions carried out in the pink and silver circles
Holistic, not just clinical
Anticipating need
Stopping a crisis
Temporary status or intervention to move people back into silver and pink circles
Creating or controlling a situation /condition rather than responding to it after it has happened
Outcomes “Do we also need to consider implications, outcomes of Care Bill?”
Integration of systems and services
Reduction in duplication
Clear pathways eg: stabilisation of condition/situation and clear pathway back to pink or silver circles
Pressures in systems are managed
Empowerment
Tools to manage better
Referral processes streamlined and timely
Individual able to manage and cope
Quality of life improved
Reduced crisis interventions eg: A&E
People move through circles as effectively as possible
Who is involved? “Appropriate Organisations”
Top Tier VCS – if resourced properly
Individuals eg: Carers
P’s (interface)
Pharmacists
Trusted professionals
Community Health and Social Care
Private sector eg: dentists, opticians etc
Vision of success Efficiently moving people out of this circle
Tools and techniques
Adjusting to new normal
Limiting movement into purple and blue boxes
Approachable, accessible advice (not information – this should occur in the pink circle)
Empowering to manage condition/circumstance and resolve situation in conjunction with planning
Social Prescribing – P’s need to recognise this model of success
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How to achieve it The group began the work on identifying how to best achieve success in this area
Pathways developed to suit needs of each individual
People looking after themselves
Snakes “Risks to exit” The group considered this area and the impact this may have. “Positive PR needed”
Holding onto budget, red-tape, processes
Knowledge – being open minded to wider holistic services/support
Secondary issues through wrong diagnosis etc
Inability to properly diagnose and manage in an effective and timely manner
Capacity eg: P’s
Ladders “Opportunities to recover” The group considered how to get people back into the “pink/silver” circles.
Green to blue circles
Help and support (short term)
Signposting and referrals (advice)
Managing/resolving situation/condition
Other Comments
Need to manage price vs quality
Model of excellence is speed and quality for client
Quality and empowerment should run through all circles
What are the risk factors?
Should “acute” be removed from the blue box? Blue circle becomes more planned and better care
The purple box should reduce
Use of appropriate resources
Circles are driven by need, people may jump around circles not just follow the arrows
See document “West Sussex Proactive Care” attached
See document “Proactive Care act Sheet Kent” attached
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3.5 Discharge Pathway
As part of the discussion the group considered the Discharge to Assess ‘circle’. Whilst recognising that this statement illustrated a medical process, the group felt that it was appropriate to include actual discharge pathways within this circle as it enabled a better illustration of a client’s needs. The group felt that significantly more could be done to ensure that the VCS provided further support to this area, building on the Home from Hospital programme currently delivered to some vulnerable groups and the advanced care planning programme.
3.6 Crisis Intervention, Admissions Avoidance and Bedded Care ‘Circles’ Whilst we did not consider the other two circles of care in such great depth as these were clinically focused areas, we recognised that the VCS is contributing and has a greater contribution to make in these areas. We also recognised the value of the private sector in potentially providing some solutions in this area and the need to engage with this group to ensure integration is universal.
3.7 Bottlenecks The group briefly considered the current and likely bottlenecks across the system which might affect any efficient and effective performance. These are illustrated in the ‘Snakes’ sections.
It was recognised that further work should be done to consider how to alleviate these barriers. These are highlighted in the ‘ladders’ section.
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4) VCS Engagement with the Well Connected Initiative
4.1 Key Players It was the group’s view that many sections of the VCS had a role to play in the development and implementation of this significant change in culture and attitude to one’s health and wellbeing. Realistically this would need to be achieved through a ‘champions’ approach where key organisations cascaded and led the transformational change programme. The Group also recognised that there were probably primary and secondary levels of engagement and commitment. It was most likely (as a result of new commissioning intentions) that primary organisations would be countywide providers and secondary organisations would fall into two categories of specialist providers by function or geography. This programme would impact significantly on the commissioning landscape and the new proposed model of commissioning by size and risk would require substantial ‘shifts in thinking’ by providers with a greater emphasis on alliancing likely. Whilst the group all felt they were key players they also recognised there may well be others who would consider themselves in that category also.
4.2 Trusted Providers
The Group did however endorse the approach and emphasised the value of strong local providers who delivered that ‘X’ factor because of their links with local communities across the county. They were seen by clients as ‘ trusted providers’.
4.3 Specialists
When dealing in the health and care environment it is obvious and necessary to address the needs of those with specialist needs. The provision of such services should be considered in all relevant work to maximise the opportunity to provide equal access to all.
4.4 Collaborative Working Streams The Group considered that further work was required by a range of providers to consider how working together might produce a more effective programme of support to the client market and deliver the outcomes needed including cost savings. This work could include co-production and co-design methods.
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4.5 Leadership Development The Group recognised the need to develop leadership skills and enable key organisations to be recognised as leading the integrated approach to service provision and support across the county.
4.6 Service Sustainability
A cornerstone to the success of early intervention programmes will be the commitment to sustaining services in the longer term to ensure that ‘slow burning’ programmes achieve their relative success values. In addition, programmes need to be sustainable either through self-reliance or from external support where obvious self-sustainability is unlikely, a good example being the provision of information, guidance and advice. This is most relevant in areas where the intervention value is critical to the overall success of the integrated care programme. The group believes more work is required to assess the criteria for valued sustainability.
4.7 Savings
On a number of occasions during the review, the group highlighted some potential savings which might be worth considering. They felt that whilst previous work had been undertaken with QUIPP and BOLD programmes, these had not looked beyond their internal remits. A piece of work could be undertaken to consider where statutory and non-statutory services were linked and could as a result offer efficiencies across the process.
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5) The Worcestershire VCS value to the Well Connected Initiative 5.1 What the VCS has to offer
This section aims to highlight the areas where the VCS believes it can provide most added value to the programme
5.2 Service Delivery The VCS are involved in service provision at a number of levels and have much
to potentially contribute. As the focus on service delivery shifts to prevention, early intervention and support in the home, the VCS can contribute with expertise in service design and delivery.
The need to clarify the capability of service providers to realistically deliver
services needs to be addressed. The Group also supports a more interactive, web based, approach to mapping service delivery and developing service provision choice for patients/clients, not least because of the emergence of the Personalisation agenda, both in social care and health. The VCS is well placed to help those who will find the interactive sourcing approaches difficult.
5.3 Experience, Expertise and Added Value The experience of coalface engagement, and the flexibility with which the VCS
works, means that it could and should be an ideal partner to enhance the integrated care programme. Besides providing excellent value for money within its sphere of engagement, it also adds value with the use of volunteers, and leverage funding, to enhance the reach and breadth of engagement and support.
5.4 Volunteering to make things happen Volunteering in the health and wellbeing environment is a unique and
demanding commitment. It cannot replace the need for proper investment in jobs and skills. It can help establish more effective compassionate communities. The investment in supporting and managing volunteers is paramount. The arguments are made elsewhere very well, but incorporating some structure and support will enable the transformation to co-ordinated compassionate communities work. Using volunteers wisely will also reduce the overall cost to the health and social care sector.
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5.5 Public Engagement and Support The VCS plays a unique role in communities. Besides sometimes being a
provider of services, it often acts as a co-ordinated voice for the public it serves. It can therefore be a significant influencer of change by the public, for the public benefit. The group recognises that further work needs to be done on establishing better public engagement at a stage in processes which is seen to realistically influence the outcome. This works equally well for practical service delivery evolution. The group would see further work on both strategic and operational service user input as being most relevant and opportune.
The group concluded that the most effective engagement of the public would
come via user groups and active supporters who could be used to inform and comment on strategies and programmes where appropriate. Investing in engagement programmes on a regular basis would facilitate this. Whilst CCS and the H&SC Trust and Acute Trust and GPs all, had patient groups, they tended to be ‘activists’ who had a specialist interest.
5.6 Self Health and Wellbeing Awareness Raising There is universal support for developing a fundamental change in the culture
of society towards taking greater personal responsibility for one’s own health and wellbeing. The group recognised that whilst not everyone can achieve full self-help, it was important to establish this goal for those in the ‘red and silver circles of care’. By implication prevention programmes would be more sustainable with short term intervention programmes and early intervention services having progressively more impact.
The group believes that the VCS is uniquely placed to be able to ‘lead’ on this element of change as it is able to ‘reach’ communities more effectively than statutory colleagues.
6.7 Leveraged Funding
The group highlighted a key positive component to the success of integrated care with the VCS was an appropriate use and alignment of leveraged funds into the county, focused on health and care interventions.
A better process of development of such funds would be of practical help to all concerned and would enable better partnership working.
6.8 Achieving Outcomes
The VCS has a history of achieving successful outcomes for both individuals and strategic commissioned services. This is a good foundation upon which to build integrated care outcome achievements.
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6) Investment in Wellbeing to Achieve the Vision
6.1 Overview As with all programmes of such magnitude, its success will be, in part,
dependent upon the right amount of co-ordinated investment. The group recognised that investment did not always mean cash. Nor did it
mean sourcing all investment from the statutory sector, although clearly it is an obvious source of cash investment. Leveraged funding, supporting a co-ordinated approach, should be actively pursued. In addition, the skills and experience of the public and those in the VCS would be an invaluable resource and investment for the programme of change required.
6.2 VCS Link Group Whilst this had been raised elsewhere, and will inevitably be a controversial
issue, the group agreed that for the VCS to contribute in a meaningful way, it needed to establish a working group which provided the Well Connected programme with both a community vision of impact and deliverability. Its value to the Well Connected programme is perhaps initially illustrated by the commitment of the group to undertake this initial work and report. Future task and finish groups and VCS contributions will need reasonable investment support to enable the appropriate contribution to be made. The concept of ‘back filling’ time could be considered.
6.3 Investment in Volunteering The group was mindful of investment being made elsewhere on the
development of generic volunteering across Worcestershire through work by Worcestershire Voices in partnership with the WCC.
Whilst this was recognised, the group felt that the recruitment, co-ordination,
management, training and motivation of volunteers in the health and social care sector was unique. The commitment required and the risks associated with volunteering in this environment, including basic costs such as DBS checking and expenses needs to be factored into any programme where volunteers are identified as adding value to a programme.
Recognising that some informal volunteering in communities which supports
health and wellbeing environments is happening and needs to continue to be encouraged, this informal approach is unlikely to achieve the outcomes needed to make a significant impact in the short or medium term and is fragmented by nature.
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The Well Connected programme offered all parties the opportunity to expand volunteering as a key added value service to the health and care sector. Work needed to be done to agree a set of investment criteria to ensure core values were met by all those involved.
6.4 Collaborative Working The group highlighted collaborative working was not a new concept for the
VCS. All those involved in the group had some form of strategic and operational partnership with other organisations. The nature of collaboration was generally driven by a mutual desire to change something which both parties felt was a priority or because the scope of a programme extended beyond the remit of the individual organisations concerned. The extent of active collaborative working was often defined by the funding investment available operationally. On the whole collaboration worked when clearly defined roles were agreed and all parties worked together to achieve them. There was significant experience of different forms of partnership working, with the best examples focussing upon service outcomes rather than structural equality. The group recognised that work was being discussed around developing collaboration elsewhere. Concern was expressed that the driver was however based on cost reduction and not on quality output improvement. The group hoped the initiative would be supported specifically for this area.
6.5 Co-design There has been much recent discussion about co-design and co-development of
programmes but the group felt this was an area that was still to be properly considered. The current unique position of the VCS as designers, commissioners and providers, with service users at the heart of their service development, makes the value of co-design well worth developing further. The transformational change required by the Well Connected initiative will not happen without some innovation occurring. Co-design programmes offer a very well evidenced way of achieving success. It needs to be trialled and tested. The investment cost is negligible and the potential impact significant.
6.6 Engagement (VCS) The group considered the relative values of engagement with the public and
other VCS organisations in relation to the Well Connected programme. The group felt the VCS offered a wide service user interface which was important when getting a balanced view.
Engagement with the wider VCS community is important as it requires a
significant positive shift in attitude of some within the VCS, not least because of other threats to the stability of organisations. The group felt that investment in key players who were recognised as strategic partners and therefore ‘leaders’ of the Well Connected change programme was politically challenging but necessary to achieve success.
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6.7 Utilisation of Existing Resources During the work undertaken there was a constant theme which emerged about
duplication of resources and overlap of programmes. The complexity and interoperability of the vast health and social care market
makes some of this inevitable. The group recognised this, but felt more could be done to highlight and address the above issue. The Well Connected programme needed to address this issue if only to act as a constructive challenging body to ensure duplication is kept to a minimum.
The group broadly welcomed the approach being taken to develop joint
commissioning with the Better Care Fund being effectively added to the joint commissioning programme.
The group felt strongly that some of the BCF fund should be focussed on
investment in early intervention and recuperation support programmes. This included new packages and a reinforcement of existing programmes.
In addition, the VCS group recognised the real opportunity to work in co-
operation to leverage in funds from other external bodies to achieve both short and longer term goals. This had been well illustrated by the development of the Social Impact Bond work which could be replicated elsewhere.
The group recognised the challenges faced by all parties influencing the
significant changes required. Running pilot programmes in parallel and without new investment meant cash flow strains, additional risks to service delivery and potentially very little room to manoeuvre because of external legal constraints. However, the group felt this was a time when engagement and co-operation was vital to enable us all to reach a positive conclusion.
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7) Recommendations
This section of the report provides some strategic development suggestions and pulls together specific recommendations to enable the VCS to engage and support the Well Connected programme more effectively. 1. The VCS Perspective
The group took a positive approach to engaging with the other organisations and groups within the sphere of the Well Connected initiative. The group felt the WC programme was not a series of disjointed efficiency saving initiatives, but a real opportunity to provide holistic, joined up services for older people in our community in Worcestershire. The work undertaken was self funded and seen as a contribution to the wider needs of our local communities. The group were however keen to establish the need for proper resourcing of such work as this was well outside their scope of normal working practices and such a commitment was, at times, challenging.
2. Care Modelling
There needs to be a recognition of, a better understanding of, and an acceptance of, the Wellbeing element of the illustrated care model. This delivers wellbeing support for people in our communities and in addition to traditional health and social care settings.
3. Defining, Linking and Mobilising the Circles of Care The individual care plans of patients/clients needs to incorporate the delivery of ‘community care’ to enhance the recovery and avoid unnecessary access to health and social care services. There should be a more comprehensive development of interventions which mitigate against individuals moving out of the ‘good’ zones and into the ‘not so good’ zones. (Dealing with the ‘snakes’). Similarly there needs to be a greater focus on holistic rehabilitation of individuals back to ‘good’ zones (leaders of support).
4. VCS Engagement with Well Connected The VCS has to consider an appropriate collaborative approach to supporting both existing programmes and facilitating new programmes which achieve the objectives. They need to be recognised and engages with by the statutory sector, creating effective strategic partnerships. There has to be common ground found for the attribution of savings identified and made between community interventions and health and social care interventions.
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Whilst savings have to be realisable, there needs to be some investment in cultural and behavioural change to enhance the programme ethos. The whole programme will rely on fundamental change in the way society views, and uses the services available.
5. The VCS Value to the Well Connected Programme There is an absolute need to introduce a model of co-design for programmes which utilises the skills and experience from individuals, specialists and community groups. This will not work for everything and it will take time to develop but it will be the basis of future personal care initiatives to be successful. Much is made about Public Engagement. In reality much of what is to be done will not be of interest to the public. The public will require clarification of accessibility to the system, a good experience when in the system and an ability to use the system in a way which suits their needs. The way to achieve this is for the advocates of the system to be those who interface with the public. Staff across the spectrum of voluntary and statutory need to understand and be advocates of the overarching programme and understand what it is doing to help them achieve more for their patient/clients. The VCS needs to deliver a comprehensive list of relevant services which can, and will, fit with the delivery of objectives and needs of clients/patients in the community care sector.
6. Investment in the programmes The H&WB Board needs to consider allocating more strategic funding to the community care elements of the programme to enable the demand to be managed more cost effectively and will achieve the cultural and behavioural changes necessary to give the initiative long term success. The VCS group welcomes the principle of re-focusing some existing investment with the clear understanding that co-design should form a key part of any refocus. The group feels strongly that a ‘pooled’ approach to leveraging funds from resources often open to VCS organisations in particular needs to be explored fully with the statutory sector, particularly to support and establish early interventions and rehabilitation programmes.
8) Conclusion
Working effectively with the VCS offers all the players the best chance of successfully achieving the cost saving programmes being considered and the more important, demand transformational change requirements necessary to make the aim of improving the health and wellbeing of older people in our communities, a success.
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9) Appendices:
9.1 Appendix 1: Participant Details
Name Title Organisation
Philip Talbot Chief Executive Officer Age UK Herefordshire & Worcestershire
Jane Longmore Business Development Manager
Age UK Herefordshire & Worcestershire
Carole Cumino Chief Executive Officer Worcestershire Association of Carers
Mark Jackson Chief Executive Officer St Richards Hospice
Peter Gill Assistant Director Housing and Communities
Fortis Living
Kate Harvey Chief Executive Officer Onside Advocacy
John Taylor Development Manager Community First
9.2 Appendix 2: List of References
1. Census 2011 – Worcestershire County Council 2. Future Lives Programme – Worcestershire County Council 3. Health & Wellbeing Strategy for Worcestershire 4. Emerging priorities for the local health & care marketplace eg: 5 year plan, CCG
priorities 5. National outcomes frameworks – Health, Adult Social Care and Public Health 6. National Voices 7. Windmill 2014 8. iMPower – A Question of Behaviours 9. The Kings Fund – Making our health and care systems fit for an ageing population 10. National Collaboration for Integrated Care and Support – Our Shared Commitment 11. Derbyshire County Council – Your Life, Your Choice Prevention Strategy 12. SCIE – Co-Production in Social Care 13. The Kings Fund – Providing integrated care for older people with complex needs 14. Local Government Association – Integrated Care Value Case 15. Public Health England – Health and Care Integration 16. Local Government – Whole System Integrated Care 17. Audit Commission – Joining up health and social care 18. Right Care – Integrated care updates 19. Monitor – Enablers and Barriers to Integrated Care 20. Age UK Integrated Care Programme
