2018 - 2021
FOREWORD
As the Chair of the Wakefield Integrated Care Partnership, I am delighted
to share with you our Connecting Care + Business Plan for 2019-2021 which
describes the priorities our system will focus on over the next three years
to deliver the vision of our Health and Wellbeing Board to have achieved
full integration of care by 2021. The Integrated care Partnership is intended
to facilitate the all age district-wide health and social care integration
agenda and to remove historical barriers that have prevented joined-up
patient care across primary, community, mental health, social care and
acute services.
The purpose of this business plan is to set out the priorities for adults and children, that need to be
achieved during 2018-2021 to enable us to realise our three strategic aims which are core drivers for
our future sustainability:
1. Promote health & wellbeing – Reducing inequalities and preventing ill health and illness
progression at individual and community level – focus is on narrowing health inequalities;
2. Admission avoidance – Ensuring fast, responsive access to care and preventing admission
avoidance to care settings, hospital emergency admissions and A&E attendances;
3. Proactive coordination of care – (or anticipatory care) particularly for people with long term
conditions and more complex health and care problems.
Through a review of our Joint Strategic Needs Analysis for Wakefield the Integrated Care Partnership
Board has identified the following five priority areas to take forward in 2018-2021:
The following business plan describes these priorities in more detail and outlines the actions we will
be progressing over 2018-2021. The idea of partnership and collaboration across organisational
boundaries is not a new concept across Local Government or in the NHS, but it is now a focus in
policymakers’ minds. The Recently Published NHS Long Term Plan states: “Local Health systems will
be expected to engage with their local communities and delivery partners in developing plans, which will
be based on a comprehensive assessment of population need. We expect that they will build on their
existing plans and set out proposals for how they will deliver the outcomes set out in the Long Term
Plan”.
“Parliament and the Government have both asked the NHS to make consensus proposals for how primary
legislation might be adjusted to better support delivery of the agreed changes set out in the Long Term
Plan (LTP). This Plan does not require changes to the law in order to be implemented. But our view is that
amendment to the primary legislation would significantly accelerate progress on service integration, on
administrative efficiency, and on public accountability. We recommend changes to: create publiclyaccountable integrated care locally; to streamline the national administrative structures of the NHS; and
remove the overly rigid competition and procurement regime applied to the NHS”. Wakefield has a
strong history of partnership working as a system, and we will continue to work together as partners
through the recently developed Integrated Care Partnership. The ICP’s aim is to ensure that we
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deliver our shared priorities and improve health and care outcomes across the district. We ask that
colleagues share this updated Business Plan within your organisations so that we can move forward
at pace in implementing our work programme for the five priority areas described within our
Connecting Care+ Business Plan.
Dr Ann Carroll
Contents Page
Foreward ................................................................................................................................................. 2
Executive Summary................................................................................................................................. 4
National Context ..................................................................................................................................... 5
Wakefield’s Local Context and what our Joint Strategic Needs Analysis tells us ................................... 6
Wakefield’s System Financial Challenge ................................................................................................. 7
Public engagement - what have our residents told us?.......................................................................... 9
West Yorkshire and Harrogate Health and Care Partnership ............................................................... 13
A vision for health and care in West Yorkshire and Harrogate............................................................. 14
Wakefield Health and Wellbeing Board................................................................................................ 16
Vision Statement of Wakefield’s Integrated Care Partnership Board and our Priorities ..................... 17
Priority Area 1: Lung Cancer ................................................................................................................ 20
Priority Area 2: Mental Health ............................................................................................................. 21
Priority Area 3: Elderly Care ................................................................................................................. 29
Priority Area 4: Primary Care Home..................................................................................................... 32
Priority Area 5: End of Life Care Integration ........................................................................................ 34
Support the triple challenge set out in the Five Year Forward View (2014)......................................... 36
Governance of Integrated Care in Wakefield ....................................................................................... 46
Key Enablers for Connecting Care + Business Plan 2019-2021 ............................................................. 47
Workforce Transformation Plan – Workforce working as ‘One Integrated Team’ ...................... 47
Communications and Engagement Plan ........................................................................................................ 50
Technology Plan....................................................................................................................................................... 50
Estates .......................................................................................................................................................................... 52
Health and Housing ................................................................................................................................................ 52
New Model of Care Board Priority Action Plans ................................................................................... 57
Enablers Action Plans Appendices ........................................................................................................ 92
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Appendix 1: Workforce Delivery Plan ........................................................................................................... 93
Appendix 2: Communications and Engagement Plan ........................................................................... 105
Appendix 3: Housing Health and Social Care Partnership Plan ........................................................ 112
Appendix 4: Connecting Care Estates & Accommodation Plan 2019/20...................................... 125
Appendix 5: Assurance Framework ..............................................................................................................128
Glossary of Terms/Acronyms .............................................................................................................. 130
Executive Summary
The purpose of this Business Plan is to set out our goals and objectives for the next two years for
integrated care across the Wakefield system. The Integrated Care Partnership have developed
ambitious plans to commission services that deliver improved outcomes, reduce health inequalities
and deliver high quality health and social care for the population of Wakefield for 2018 - 2021.
The Business Plan aims to provide a level of assurance for both the Health and Wellbeing Board and
the Integrated Care Partnership for the need to develop and deliver key priority workstreams across
the Wakefield Health and Social Care System. This is in order to optimise the existing and future
workforce and provide sustainable services that deliver high quality health and social care for the
population of Wakefield.
This plan sets out the system wide strategy alongside our vision, values and priorities for 2018 to
2021 and includes specific delivery plans for implementation over the next three years. The purpose
of our planning activity is to set out our vision for local health and care services, based on identified
needs, and to allow us to see how our plans are aligned with the requirements of the NHS Long Term
Plan (2019), the Long Term Plan Implementation framework and the NHS Constitution.
The plan also incorporates strategic goals and gives a clear and credible plan for the commissioning
and delivery of health and care services in Wakefield.
This plan outlines the Boards’ approach going forward for the next three years (2018-2021)
including:
 Promote health & wellbeing – Reducing inequalities and preventing ill health and illness
progression at individual and community level – focus is on narrowing health inequalities;
 Admission avoidance – Ensuring fast, responsive access to care and preventing admission
avoidance to care settings, hospital emergency admissions and A&E attendances;
 Proactive coordination of care – (or anticipatory care) particularly for people with long term
conditions and more complex health and care problems.
The Integrated Care Partnership Business Plan builds on the achievements of the Wakefield
Connecting Care+ to set out our priorities and strategic direction over the next 3 years. The delivery
of this plan will contribute to the delivery of the Wakefield vision of creating person centred coordinated care, which lies at the core of everything we strive to achieve working with our partners in
Connecting Care Health and the Social Care Partnership.
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Ongoing work by the Integrated Care Partnership Board in the form of development sessions to
determine the focus for the Wakefield health and care system, coupled with intelligence from the
JSNA has enabled the onging development of the five priority areas. Following a further
development session in January 2019, the Integrated Care Partnership agreed to continue
developing the same five previous priorities across 2018-2021:
National Context
This plan sets out the system wide strategy alongside our vision, values and priorities for 2018 to
2021 and includes specific operational plans for delivery over the next three years. The purpose of
our planning activity is to set out our vision for local health and care services, based on identified
needs, and to allow us to see how our plans are aligned with the requirements outlined in legislation
that outlines our statutory responsibilities to integrate care in both the Health and Social Care Act
(2012) and the Care Act (2014).
This business plan was developed to outline our local response to the following policy guidance
requirements that are focused on integration of care such as ADASS/LGA Stepping up to the Place
(2016), the NHS Five Year Forward View (2014), the NHS Long Term Plan (2019) and the NHS
Constitution. Both the NHS and Local Government are moving in the direction of place-based
systems of care ‘in which health and social care work together to improve the wider determinants of
health of the population’ (King’s Fund, 2015). “The divide between primary care, community
services, and hospitals – largely unaltered since the birth of the NHS – is increasingly a barrier to the
personalised and co-ordinated health services patients need” (FYFV, NHS England, 2015), “Breaking
down traditional barriers between care institutions, teams and funding streams so as to support the
increasing number of people with long-term health conditions, rather than viewing each encounter with
the health service as a single, unconnected ‘episode’ of care” (LTP, NHS England, 2019).
Developing and mobilising new care models are key to the delivery of the ambitions set out in the
NHS Long Term Plan, with a focus on both NHS and care services closing the finance gap, care and
quality gap, and improving community wellbeing.
NHS England and NHS Improvement have recently refreshed planning guidance for 2019/20. The
guidance defines the expectations for Integrated Care Systems (ICS) to take an increasingly
prominent role in planning and managing system-wide efforts to improve services. We will work
with the West Yorkshire Integrated Care System to support the development and implementation
the Integrated Care System five year plan, wider strategic vision and also enable the delivery of the
Integrated Care Partnership business plan 2018-2021.
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Wakefield’s Local Context and what our Joint Strategic Needs Analysis
tells us
The population of Wakefield is estimated to be around 340,000 people, which is expected to grow to
around 351,000 in the next five years. Wakefield is also expected to encounter a large population
structure change, with the over 65 population group growing by over 23 per cent by 2030. As a
corollary to this, the working age population is only predicted to grow by approximately 0.8 per cent
by 2030 (about 1,800 additional people in the theoretical workforce). Implications of an ageing
population are wide in terms of people living longer into older age with a higher burden of chronic
disease, an increased demand for health and well-being services, a reduction in working age people,
a reduced contribution to the economy and lower incomes, and increased human resources for care
services (paid and unpaid carers).
Wakefield ranks as the 65th most deprived local authority out of 326 putting it in the top 20 per cent
most deprived local authorities. There are stark inequalities in health in the district with men in
poorer areas living on average 8.5 years less; 9.1 years for women (2015-17). There is unwarranted
variation of life expectancy in Wakefield and the Integrated Care Partnership has a key role to play in
securing better outcomes for the population and reducing unwarranted variation and health
inequalities.
Poverty and inequality manifests in many ways in a health and care system, locally we see increase
demand on health and care services. Wakefield has higher rates of long term conditions than the
national average and we estimate that there are a number of people who remain undiagnosed. A
disproportionately large amount of life-years in Wakefield are lost in the most deprived communities
to chronic heart disease (CHD), lung cancer, stroke, chronic obstructive pulmonary disease (COPD)
and – particularly in men – chronic liver disease. Due to the increasing elderly population with
multiple long term conditions it is anticipated that demand on health and care services will further
increase. A example of this is that as the District’s population gets older, we can expect to see a 25
per cent increase in the number of people living with dementia in the next 10 years with significant
implications for health and social care services.
The main population risk factors are smoking (19.3 per cent of the population, 2018), excess weight
(60.7 per cent, 2017/18) and high blood pressure (15.3 per cent, 2017/18). If these risk factors could
be reduced in the population even just by a few percent, we would see a significant reduction in the
number of people experiencing poor health. Wakefield has some of the nation’s highest rate of lung
cancer deaths, in the latest information available Wakefield ranks 120 out of the 150 unitary
authorities. Deaths from lung cancer alone account for over 250 of the 3300 deaths each year in the
district.
Poor mental health has long been an issue for the district, many of the annual population survey
over the last decade have indicated this. The area has had higher than national average of common
mental health disorders such as depression and anxiety. In the young, self-harming has been
increasing in the district particular for young women. Suicide prevalence has also been on the
increase across the district particularly in middle aged men. For the older age groups social isolation
and loneliness should also be taken into account as a key factor influencing quality of life, health
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outcomes and service demand. Being lonely has been estimated to have the same negative effect on
health and wellbeing as smoking 15 cigarettes a day.
Elderly care for multiple reasons is to become a pressure for the health and care services locally. The
facts of aging presents the likelihood of development of more long term conditions. Multi morbidity
is not solely an issue for older age groups, but does present more commonly in those groups. The
result of having more complex patients to manage is increased demand on health and care services.
Nationally, this work has been modelled to show that as the baby boom cohort age and present with
multiple long terms conditions we can expect to see significant health service and social service
provision being required. Preventing the development of long term conditions and better
management of the existing ones, will increasingly be more and more important to prevent
premature mortality.
End of life care and having the choice about where you spend your final days has been a clear drive
within health and care services for many years. Since 20101, Wakefield has seen a great increase in
the number of deaths within the hospital setting locally. The proportion of people in Wakefield who
die in their usual place of residence is increasing, but at a slower rate than in other comparable
areas. Those dying from Circulatory disease or Dementia and Alzheimer’s disease in Wakefield are
less likely to die in their usual place of residence than in other comparable areas. Supporting people
who choose to die in their usual place of residence both improves quality of care and reduces
demand on acute services.
Key to helping improve Lung Cancer, Mental Health, Elderly Care and End of Life care is reaching
people sooner and managing them more affectively. Primary Care Home is an innovative approach
to strengthening and redesigning primary care. The model brings together a range of health and
social care professionals to provide enhanced personalised and preventative care for their local
community. Staff come together as a complete care community – drawn from GP surgeries,
community, mental health and acute trusts, social care and the voluntary sector to focus on local
population needs and provide care closer to patients’ homes.
Wakefield’s System Financial Challenge
The Wakefield System Financial Position:
As outlined in the Strategic Case, the Wakefield District includes pockets of significant deprivation,
with both Wakefield and North Kirklees being amongst the most deprived 20 per cent of wards in
the UK. Wakefield follows a national picture where the population structure is shifting towards that
of an ageing population. The implications of this are well stated, with an increased demand placed
on health and social care services, a growing need for paid and unpaid carers, combined with a
reduction in working-age people.
Population projections demonstrate that Wakefield is expected to encounter a large population
structure change within the next five years, with the older persons grouping growing by over 22 per
cent by 2021 (80,900 persons). By 2025, the Wakefield population will see a doubling of men aged
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85 and over. By 2031, the older person population is expected to have grown by over 50 per cent,
representing a population close to 100,000. These demographic dynamics present a clear challenge
to health and social care services in the District, and demand new and innovative approaches to
delivery in order to meet the needs of the Wakefield community.
In March 2016, the Wakefield Local Services Board commissioned PwC to undertake a review,
referred to as ‘The Single Version of the Truth’ (SVT). As part of their work, PwC worked across the
Council, Wakefield CCG, Mid Yorkshire Hospital NHS Trust and South West Yorkshire Partnership
Foundation Trust carrying out financial modelling and benchmarking to analyse the case for change.
This involved assessing the projected cost savings based on the different optional models to outline
the financial challenges and the gap the system needs to address over the next five years. This SVT
project aims to create a five year forward view of financial sustainability for the Wakefield Health &
Social Care System. This work was completed by June 2016 and the SVT concluded that:
 If the Wakefield system made no efficiencies between now and 2020/21, the gross system deficit
would be £182m;
 A review of organisational plans indicates that the system has identified significant savings and
efficiency plans (the PwC model risk-adjusts various input elements).
Since the publication of the SVT, Health and Social Care systems have submitted financial plans as
part of the development of the West Yorkshire Sustainability and Transformation Plan (STP).
National guidance was issued to aid production of STPs in a more consistent way across the country.
This guidance included a refresh of previous assumptions on inflation, efficiency, growth, national
requirements for investments and business rules. There was also further development on solutions,
particularly on the WY wide programmes. These factors had an impact on the financial modelling for
the STP and as a result, changes were made which provided a more up to date financial plan than
the SVT, although many of the same principles still applied. For the Wakefield patch, the current STP
model (submitted 21st October 2016) shows the following:
Figure 1 – STP financial modelling
In summary, a ‘do nothing’ scenario would result in a system wide deficit of c£237m by 2020/21.
Solutions provided in the collective STP are £192m against this system challenge and are further
expanded in the chart below:
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Figure 2- STP Solutions
In summary the ‘Single Version of the Truth’ (SVT), a financial assessment of the Wakefield Care
economy by PwC, showed that the economy would be facing an in-year deficit of £181.7m in
2020/21 in the case of a ‘do nothing’ scenario. However, since the publication of the SVT, national
guidance towards the development and production of STPs included a refresh of previous
assumptions on inflation, efficiency, growth, national requirements for investment, and business
rules. These had an impact on the financial modelling for the STP, and as such, the STP provides a
more up to date financial plan. The current STP for Wakefield, as submitted on 21st October 2016,
shows that a ‘do nothing’ scenario would result in a system wide deficit of c£237m by 2020/21.
Solutions provided in the collective STP are £192m against this system challenge.
With prominent system pressures across the NHS and social care environment, Wakefield system
leaders recognise that we need to engage with new ways of working to help close this gap. By
expending and building on the work of the Meeting the Challenge Programme and other
transformation work underway across Health and Social Care it will be critical to understand how the
Integrated Care Partnership five priorities will contribute to supporting to close the gap described
above. The system challenge from implementing the new models of care on a whole population
basis is to realise this benefit over the next 5 years in a recurrent and sustainable way and possibly
go even further in order to close the remaining gap. It is therefore imperative that the new operating
model to deliver our out of hospital care model at scale (Connecting Care+), provides a return on
investment. This will be described further in the Triple Aim section of this business case.
Public engagement - what have our residents told us?
The Five Year Forward View describes how the health service needs to change, arguing for ‘a more
engaged relationship with patients, carers and citizens so that we can promote wellbeing and
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prevent ill-health.’ It states that ‘we need to engage with communities and citizens in new ways,
involving them directly in decisions about the future of health and care services.’
In Wakefield, this has been taken seriously from the very beginning of our journey to integrate
health, social care and voluntary sector services. Since 2014 we have engaged with hundreds of
local people; testing out ideas, asking their opinions of services, gathering stories and feedback and
evaluating health and care initiatives.
Connecting Care. Our most influential engagement with local people and evaluation of service
change was conducted from 2014 through to 2017.
Healthwatch Wakefield as our local health and care consumer champion, was commissioned to
provide an element of independence to the evaluation. Nearly 800 interviews were carried out with
patients and carers who were receiving services from our integrated Connecting Care hubs. These
interviews were conducted by Healthwatch Wakefield, working with lay interviewers to talk to
people in their own homes.
This involvement with patients and service users has resulted in demonstrable change:
 Healthwatch found that people had better outcomes with a named co-ordinator, so the
Connecting Care+ structure now includes a Care Co-ordination Unit;
 Healthwatch highlighted the difficulties faced by carers and now there is a post within Public
Health responsible for carers issues and more support to Carers Wakefield;
 Healthwatch showed a statistically significant correlation between social isolation and poorer
health outcomes, leading to a focus on loneliness within Connecting Care+ and more widely.
Care Homes Vanguard: In 2015 and 2016, Healthwatch Wakefield conducted interviews with 74
residents of 3 care homes in the district, before and after Care Homes Vanguard team interventions.
As a system we gained an insight from this work into the complex nature of healthcare delivery in a
care home setting, and useful information about what residents feel gives them a good quality of
life.
We also used national visits and channels to gather feedback on the programme. Professor Don
Berwick, former health adviser to President Barack Obama, visited our care home vanguard in
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January 2017 (video here) alongside NHS Confederation visiting in January 2018, which led to a
national podcast being recorded to share our work (podcast here).
Multispeciality Community Provider (MCP) Vanguard: From 2016 to 2017, Healthwatch Wakefield
conducted evaluation of various strands of activity, 870 interviews in total:
Public Views on Integrated Care. In late 2016, we identified that it would be useful to conduct some
specific engagement with the public about the move towards integrated health and care services.
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We commissioned Healthwatch Wakefield to conduct focus groups with local people. 8 focus groups
were conducted in the community with 83 people contributing their thoughts:
GP Extended Hours: Between April and July 2017 Wakefield NHS Clinical Commissioning Group
(CCG) engaged with patients about how we might provide urgent primary care
services. Engagement was based on previous feedback received in 2015 about primary care
services. The service would be accessed by phoning the normal GP number. Patients would be
triaged by a nurse or doctor and treated as appropriate. The service would be available 6.00pm10.00pm weekdays and 9.00am-3.00pm weekends and Bank Holidays. People generally thought this
was a good idea and would improve current services. We received many useful comments that
helped to shape and improve the service. These were around the service needing to be easily
accessible, and communicated widely to the public.
Self-care, sharing care records and telehealth: In the winter of 2017 the CCG engaged with the
public about self-care, sharing care records and telehealth. This built on engagement undertaken by
Healthwatch the previous winter. 240 survey responses were received and face to face discussions
took place with over 90 people:
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Engagement with local people continues to take place, with current work streams evaluating:
 Experiences of discharge from hospital
 Pharmacy in General Practice
 Holistic interventions in Supported Living Settings
 Shared decision making for people with long term conditions
 Care homes evaluation with NHS England
West Yorkshire and Harrogate Health and Care Partnership
Since 1948, the NHS has adapted itself and must continue to do so as the world and our health
needs also change. There are extensive opportunities to improve care by making common sense
changes, which includes the NHS and local government coming together in 44 areas, covering all
England to develop proposals for health and care. In November 2016 draft proposals for our
Sustainability and Transformation Partnership were published. The proposals described, how we
will work together on the “triple aim” of the Forward View: to improve the health of people; provide
better care; and ensure financial sustainability.
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A vision for health and care in West Yorkshire and Harrogate
The purpose of our West Yorkshire and Harrogate Health and Care Partnership is to deliver the best
possible health and care for everyone living in the area. West Yorkshire and Harrogate is the second
largest health and care partnership in the country, covering a population of 2.6 million. There are
very diverse demographics and socioeconomics across the West Yorkshire and Harrogate footprint,
for example a 10 year variation in life expectancy across Wakefield, with pockets of high affluence
and high deprivation.
As a system, we all agree that working closely together is the only way we can tackle these
challenges and achieve our ambition and over the past fourteen months our partnership has made
major strides towards working together. There are six places that make up the partnership:
Bradford District and Craven; Calderdale; Harrogate & Rural district; Kirklees; Leeds and Wakefield,
which mirror local government boundaries and is centred on our Health and wellbeing Boards. The
partnership aims to deliver improvements in the quality and value for money of care provided, by
working through nine programmes and six enabling workstreams:
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The West Yorkshire and Harrogate Partnership firmly believes the principle that services should be
delivered as close as possible to people in their own home and communities where safe and
effective. The local plans and the nine priorities make up the West Yorkshire and Harrogate Health
Care Partnership Plan. The service delivery model outlines the place- based connected services;
West Yorkshire and Harrogate clinical networks; and Single West Yorkshire and Harrogate services.
Local plans are the foundation of what will be delivered in their area and they set out how the
improvements from the new ways of working and prevention will be made. The place plans focus on
aligning primary and community care and we are putting greatest emphasis on helping people in
their neighbourhoods and managing demand on services.
The place plans focus on improving health and well-being and the other factors that affect health,
such as employment, housing, education and access to green spaces.
Taking a common approach to these services across West Yorkshire and Harrogate will enable
different organisations and services to work together more easily. This may be achieved through
networks, partnerships between organisations or other ways of working.
Change needs to happen as close to people as possible, putting the person at the centre of what we
do. This is why local relationships are the basis for the plans. The Integrated Care Partnership Board
will work closely with the West Yorkshire and Harrogate Health and Care Partnership to understand
the work programmes and work together to deliver the ambition to improve health and care across
the system. We all agree that working more closely together is the only way we can tackle these
challenges and achieve our ambitions. It is the only way we can genuinely put people, rather than
organisations, at the centre of what we do. It is also the only way we can maximise the benefit of
sharing the expertise and resources we have, including money, buildings and staff, to achieve a
greater focus on preventing ill health and reducing health inequalities.
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Aligning with the vision of the West Yorkshire and Harrogate Health and Care partnership, the
Connecting Care+ business plan will utilise the latest technology to give the local population of
Wakefield the best health recovery possible, such as developing local or regional shared health and
care record and development of a person held care record. It is recognised that our workforce is our
best asset, and the workforce plan within the Connecting Care+ business plan aims to develop and
train staff to give the best possible care.
The Connecting Care+ business plan will also look to address the priorities of the West Yorkshire and
Harrogate partnership, by aligning to the work to support primary and community care. Some of
this will be achieved by the development and mobilisation of Primary Care Homes across the district
to support the health and wellbeing of everyone in the community, including GP’s, pharmacies,
community mental health teams and social care.
Preventing ill health and improving wellbeing is the essence of the West Yorkshire and Harrogate
Health and Care Partnership, and the Connecting Care+ business plan has aligned key priorities of
the Integrated Care Partnership Board with the vision of the strategy. This includes working with the
partnership on improving the lung cancer outcomes, particularly our ambition around reducing the
smoking prevalence from 17.4% to 13% by 2021.
There is also strong evidence that tackling mental ill health early improves lives and this is a priority
at both West Yorkshire and Harrogate partnership level and the ambition of the Wakefield
Integrated Care Partnership
Wakefield Health and Wellbeing Board
The Wakefield Health and Wellbeing Board sets the strategic direction and vision for health and care
across the Wakefield District and in 2016 following the publication of ‘Delivering the Five Year
Forward View’ the Board agreed a plan which, following the publication of the NHS Long Term Plan,
was found to align extreamly well. The plan acts as both a place plan under the West Yorkshire and
Harrogate Health and Care Partnership and the Health and Wellbeing Board Strategy. The Wakefield
Health and Wellbeing Plan 2016/21 had a set of six priorities outlined below which it sought to
achieve, supported by a number of enabling strategies including workforce, estates and digital.
The work of the Intergrated Care Partnership directly supports delivery of the plan, in particular the
delivery of ‘New Accountable Care Systems to deliver new models of care’. Creating person centred
co-ordinated care is outlined in the plan as being the Wakefield vision, not just in Connecting Care
but in everything we do. Alongside the priorities in the plan there were a number of ‘Must Do’ asks
set by NHS England for which the plan demonstrates what in Wakefield we will do to achieve them,
all of which are areas which are highlighted in the Joint Strategic Needs Assessment as above. These
include our approach to tackling cancer and in particular early diagnosis, how we plan to deliver the
newly published Primary Care network Direct Enhanced Service, and how we intend to improve
outcomes in mental health, all of which have been prioritised for focus under the Intergrated Care
Partnership.
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We have already set out in this document a number of the drivers for change, not least the updated
Joint Strategic Needs Assessment, local context, public engagement and the latest update on the
West Yorkshire and Harrogate workstreams ‘Our Steps to Better Health and Care for Everyone’.
Given this context in July 2018 it was agreed by the Health and Wellbeing Board refresh Wakefield’s
Health and Wellbeing Plan. The monitoring and delivery of the four key priorities for the Health and
Wellbeing Board will be taken forward by both the Children and Young People’s Partnership and by
the Integrated Care Partnership Board who are in effect key delivery partnerships to deliver
Wakefield’s Health and Wellbeing Plan.
In March 2018 the Health and Wellbeing Board agreed to reframe their priorities and agreed to
frame these in same way highlighted by Marmot and these priorities were approved by HWB in July
2018. The four Health and Wellbeing Board priorities are:
 Ensuring a healthy standard of living for all. This would capture the developing work under the
Early Intervention banner and the work of the Community Anchors and Community Asset Based
Approach to community regeneration. This could also include the work of the Health and
Housing Partnership and how as organisations we tackle poverty in the district.
 Giving every child the best start in life. This links closely to the work of the Children and Young
People’s Partnership and would encompass the ‘First 1,000 days’ work being led by Public health,
including school readiness, childhood obesity, child poverty and early intervention.
 Strengthening the role and impact of ill health prevention. This priority supports the move to a
left shift, with a focus on self-care. the work streams of the ICP Board whilst cutting across all
four priorities particularly has a natural home here with mental health, cancer, frailty, primary
care home and end of life care. It will also include our maturing work around wider determinants
of health and again in particular health and housing.
 Creating and developing sustainable places and communities. This priority embodies the
concept of ICP, doing things differently and captures some of our enabling work streams of
workforce, digital, estates and communications. It will have the detail around harnessing the
power of our communities and working with our local businesses.
Vision Statement of Wakefield’s Integrated Care Partnership and our
Priorities
“Creating person centred co-ordinated care” is at the heart of Wakefield’s approach for driving
forward integrated care and lies at the core of everything we strive to achieve working together as
partners of the Integrated Care Partnership. The challenges facing health and social care are well
stated, with numerous drivers evident in relation to health and wellbeing, care and quality, and
effectiveness. Innovative approaches are required.
The Integrated Care Partnership which has developed our refreshed Connecting Care + model is
about integration and removing historical barriers that have prevented joined-up preventative
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patient care across primary, community, mental health, social care, childrens and acute services.
The Integrated Care Partnership provides a core platform from which radical change and
improvement in the ways in which communities interact with health and social are services can be
developed and sustained.
The Connecting Care + model is designed to dismantle divides and improve the co-ordination
between separate groups of staff and organisations. It involves re-designing care around the health
of the population, irrespective of existing institutional arrangements. It is about creating a new
system of care delivery, supported by an effective and robust financial and business model.
This means developing and embedding innovative patterns of engagement throughout a system that
currently exists in separate parts. The promotion of public health, effective deployment of multidisciplinary teams, ease of access for the public to services, and the best use of technology are all
elements which cannot operate in isolation and must be utilised and delivered in collaboration in
order to fulfil the aims and opportunities available.
A successful Integrated Care Partnership will see care delivered closer to home, fewer trips to
hospital, improved co-ordination of support, better access to specialist care in the community, and a
promotion of public health and wellbeing and the tools for greater self-care. Through our new model
of care in Wakefield we will strive to ensure equity of provision across the district, no matter where
people live in their community, whether in their own home, a care home or an assisted living
environment.
Our Connecting Care + vision is to ensure our residents are able to:
To turn this vision into reality the Integrated Care Partnership Board has adopted three high level
strategic aims which are:
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We have ambitious plans to make Wakefield a healthier place to live and to ensure that wherever
possible we diagnose and prevent risks to health before they materialise. We will place the greatest
emphasis on quality and person centred co-ordinated care outcomes from the services we both
commission and deliver.
Our programmes of work will be underpinned by promoting integrated ways of working that support
the patient, families and carers to take more responsibility for their own health in terms of staying
healthy and in accessing the right care in the right place at the right time.
The Integrated Care Partnership Board have a key role to play in leading the delivery of the overall
objectives and priorities adopted and therefore have undertaken development sessions as a Board
to develop priority workstreams that will support the delivery of our strategic objectives. Each
priority is led by a Board member working in collaboration with other colleagues.
The five key priority areas which have been recommended for prioritisation within the Integrated
Care Partnership Business Plan 2019 – 2021, are as follows:
1. Lung Cancer – Integrated sequence of interventions for lung cancer health checks
Lead: Professor Sean Duffy/Dr Abdul Mustafa Project; Programme Lead: Hazel Taylor
2. Mental Health – System approach to provision of Mental Health services
Lead: Rob Webster; Project Manager: Alix Jeavons
3. Elderly Care – Ensure improved coordination and communication across primary care and
secondary care using Connecting Care plus focussing on admission avoidance for those identified
as elderly and/or Frail
Lead: Dr Ann Carroll; Project Manager: Martin Smith
4. Primary Care Home – Vehicle for care integration for registered populations of 30,000 – 50,000 in
geographical communities
Lead: Sean Rayner; Project Manager: Nick Sutton
5. End of Life Care Integration
Lead: Dr hazel Pearce & Dr Abdul Mustafa ; Project Manager: Michala James
The five key workstreams above form the Integrated Care Partnership programme of work for 20192021. The delivery of this programme of work will be overseen by the Integrated Care Partnership
Programme manager, Nick Sutton. (Nick.Sutton@wakefieldccg.nhs.uk)
These priority areas will be realised in partnership with the Integrated Care Partnership Board as the
vehicle for transformation and positive change.
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Priority Area 1: Lung Cancer - Integrated sequence of interventions for
lung cancer health checks
Rationale
Cancer in West Yorkshire and Harrogate (WY&H) Alliance is a major contributor to premature death.
Many CCGs in WY&H have higher Age Standardised Rates (of cancer incidence and deaths) than the
England national average in both incidence and mortality. This means that given the population size
for each CCG, a higher number of people than expected are either being diagnosed with, or dying
from cancer compared to the national average.
Lung cancer is the most common cancer in West Yorkshire; in contrast data for England shows it to
be the third most common behind breast and prostate cancer. Analysis of outcomes for lung cancer
in West Yorkshire and Harrogate has identified that Wakefield and Bradford are the health systems
where there is most to be gained if some interventions are implemented. In both localities, there
are a combination of poor outcomes and high smoking prevalence. As a result of this analysis, the
ICP Board has identified lung cancer as a priority area to be developed.
In the lung cancer pathways delays can mean a change from treatable cancer to palliative
management – time matters. For some patients, it is a complex pathway and so can be difficult to
establish a definitive histological diagnosis but there is a price to pay if the delays are not tackled. In
terms of system performance on key CWT operational standards, if the lung cancer pathway was to
perform optimally (85% patients treated within 62 days), this would translate to an overall system
wide improvement in 62 days of 13%.
Gaps and Actions 2019/20
A proposal for an integrated sequence of interventions has been developed to support a greater
synergistic impact on improving outcomes overall.
1. Optimising smoking cessation support, using the acute sector to promote smoking cessation
through Every Contact Count for example, signposting in the acute sector, carbon monoxide
monitoring for every elective admission and initiating nicotine replacement prescribing (the
Ottawa model)
Impact: Reduction in smoking prevalence, reduction on re-admission rates and hospital mortality
(Ottawa data)
2. Adopt and plan “Push and pull” symptom awareness campaigns and community engagement
events using the national cancer communications materials and smoking campaigns Stub it out,
Keep it out, Breathe 20/25). The nationally developed Be Clear on Cancer campaign material
could be used through social media (expertise already developed through the recent national
respiratory symptoms campaign). In addition, the approach used for the “Cough Campaign”
material which was successfully employed in South East Leeds could be considered.
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Impact: Reduction in cancers diagnosed as an emergency presentation, more cancer diagnosed
overall and more people offered curative surgery (earlier stage diagnosis).
3. Risk identification in primary care to promote direct to Low Dose CT (LDCT) scanning, using the
Manchester Cancer Improvement Partnership community based ‘Lung Health Check’ model. This
combines identification of the risk population, invitation to a lung heath check and the
deployment of local community based LDCT scanning. There is an added benefit of detecting
significant other non-cancer diagnoses. It also allows the deployment of the mobile CT resource
as part of the CTF fund allocation.
Impact: More lung cancers diagnosed overall and at an earlier stage offering surgical treatment.
4. Optimising the lung cancer pathway to ensure patients are speedily and optimally managed, in
tandem with the system wide approach across the whole alliance.
Impact: Improvement in 62 day pathway overall.
Priority Area 2: Mental Health – System approach to provision of Mental
Health services
Rationale
In 2014, the Mental Health Strategic Programme Board identified seven outcomes to be achieved
through a programme of transformation. Some good progress has been made towards achieving
those outcomes however to truly deliver the ambition of holistic care and support that enables
Wakefield residents to fulfil their potential and live well in their community, fundamental changes
need to be made in how partners work together as a system to put the patient first.
In Wakefield:
 1 in 7 adults are recorded as having depression or anxiety.
 1 in 3 people in Wakefield report they have been diagnosed with a common mental health
disorder at some point.
 There are 25-30 suicides per year in the district.
 30% of people with a long term condition will experience mental health problems and 46%
of people with a mental health condition will have associated long term conditions.
For children and young people;
 50% of adult mental illness starts before age 15 and 75% before age 18.
 2 out of 10 children live in poverty in Wakefield.
 More than 200 young people were admitted to hospital because of self-harm last year.
The ambition is to reimagine mental health care; starting with a renewed focus on providing early
help and supported self-care; utilising all assets within communities including, arts, sports, faith,
peer led approaches and world class, evidence based specialist care in all settings.
Providing integrated, holistic care at the point of delivery regardless of location or primary need is an
underpinning principle, alongside investing in the workforce so that high quality holistic care can be
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provided and co- producing new approaches and pathways with service users, carers and residents
so that individuals can reach their potential.
The aim of the Mental Health Alliance is to develop a single shared accountability for local plans, the
Mental Health Investment Standard, the delivery of the NHS Long Term Plan and delivery of the final
two years of the Mental Health Five Year Forward View.
The Mental Health Five Year Forward View set out that “The NHS needs a far more proactive and
preventative approach to reduce the long term impact for people experiencing mental health
problems and for their families, and to reduce costs for the NHS and emergency services”.
In 2018, set in the national context of the Mental Health Five Year Forward View and building on the
existing integration journey in Wakefield, providers of Mental Health services across Wakefield came
together to accelerate the development of a new approach to mental health across the district by
strengthening partnership arrangements through an alliance of mental health providers.
Led by a strategic leader of Wakefield Integrated Care Partnership (ICP) the aim is to reduce
variation in quality, improve outcomes and drive efficiency to ensure the sustainability of services.
The shared vision is to “Provide holistic care and support that enables Wakefield residents to fulfil
their potential and live well in their community”.
Gaps and Actions 2019/20
In March 2019, the Wakefield Mental Health Alliance considered the national priorities and the
local challenges and identified the following priorities:
1. To reduce mental health crisis episodes and dependence on urgent care services by expanding
services for people experiencing mental health crisis
2. To improve support for people with mental health and chaotic lifestyles to improve their
individual outcomes and support them to live well in their communities
3. To reduce the incidence of suicide
4. To transform Children & Young People’s Mental Health services so that young people are able
to access the appropriate support, crisis are prevented and individual outcomes and improved
5. To review and transform services for people living with Dementia to ensure Wakefield is a good
place to live and a good place to die with Dementia
1. The following schemes are designed to improve how the system
responds to those in mental health crisis, and to prevent crisis for
occurring.
Increased capacity in Intensive Home Based Treatment (IHBT) Team
NHS England expects that Intensive Home Based Treatment Teams will meet the Core Fidelity
standard by 2021. A review of the Wakefield service has identified the following areas that will be
subject to increased investment and improvement in 2019/20:
 Need to assess carers needs and offers carers emotional and practical support
 Need to offer psychologically informed interventions
 Need to be a full multi-disciplinary staff team with staffing which includes dedicated time from:
i) nurses; ii) occupational therapists; iii) clinical or counselling psychologists; iv) social workers;
v) psychiatrists; vi) service user-employees; vii) other support staff without professional mental
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health qualifications; viii) pharmacists ix) Approved Mental Health Professionals or equivalent;
x) non-medical prescribers; xi) family therapist; xii) accredited cognitive behavioural therapist
Need to increase skills and specialist knowledge within IHBT in responding to service users with
highly complex presentations resulting from having a drug and alcohol presentation or having a
chaotic lifestyle, often associated with a personality disorder.
The impact of these changes will be monitored by the Mental Health Alliance.
Provision of a new 24/7 Mental Health Helpline
A new helpline will be commissioned across Calderdale, Kirklees, Leeds and Wakefield.
The service will be accessed by individuals with mental health needs and their families and carers.
The service will enable individuals to receive advice, information and guidance during the hours
when statutory mental health services are not readily available. The service will be designed to
respond to urgent concerns and will operate within a recovery model ensuring callers’ benefit from
an effective intervention.
Increased capacity within the Police Liaison service
During 2019/20 an assessment response service will be established to complement and enhance
existing SPA, IHBTT, PLT, 136 and CAMHS resources, aligned to the proposal to increase capacity in
IHBTT and provision of a 24/7 helpline.
The service will provide:
 comprehensive phone based information and guidance to partners
 attendance at call outs if deemed appropriate and beneficial (community assessment)
 site based assessment if appropriate (alternative to 136 detention)
Provision of a new VCS Grant Fund
It is recognised that the contribution of voluntary and community sector groups in preventing crisis,
and supporting people to maintain their wellbeing is often underestimated.
In line with the approach taken under the Live Well contract, it is proposed that a VCS Grant Fund be
established for organisations to propose schemes that prevent mental health crisis. The fund would
be administered by NOVA on behalf of the Mental Health Alliance and would be available twice per
year. Key outcomes will be captured, demonstrating the impact each scheme has had.
2. The following schemes are designed to improve support for people
with mental health and chaotic lifestyles.
Provision of a new Safe Space
Run by trained peer support workers (as part of the Peer Support Network), the Safe Space will
equip the Wakefield system to respond in a more proactive and appropriate way to individuals
experiencing a multitude of complex mental health and social problems that often result in crisis.
Learning from the development and success of other local models including Dial House in Leeds, The
Sanctuary in Bradford, the Basement Project in Halifax and the Safe Space in Halifax, the Safe Space
will;
 Promote and support “recovery” in a person-centred way
 Reduce crisis episodes and emergency MH admissions
 Improve the system’s ability to respond to crisis and provide a genuine alternative to a S136
detention or a mental health admission.
 Reduce inappropriate A&E attendances.
 Improve the Peer Support Worker’s ability to manage their own mental health
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Increase self-esteem and confidence of the Peer Support Workers
Support the ongoing professional development of the peer support workers
Develop a sustainable ‘blueprint’ for supporting peer support workers across Wakefield and
provider partners with robust infrastructure and governance support.
The Safe Space will initially be open 6pm – 2am Friday, Saturday and Sunday.
New capacity to offer Dialectic Behavioural Therapy within Community Mental Health Teams
As part of the intelligence gathering to inform the development of the Safe Space, it has been
identified that there is a need for evidence based therapy interventions for individuals with a
Personality Disorder presentation who exhibit high risk behaviours such as deliberate self-harm and
suicide attempts.
Dialectical Behaviour Therapy (DBT) fulfils the recommendations in the NICE guidance for Borderline
Personality Disorder and is a NICE recommended intervention for those who present with high risk
self-harm behaviours. DBT programmes have a positive impact on an individual’s quality of life and
can reduce hospital admissions and A&E attendance.
Dialectic Behavioural Therapy training
To support the delivery of DBT therapy, it is proposed that training provision is secured.
Increased capacity to develop Multi-Agency Care Plans to support the Serenity Integrated Model &
membership of the Network
The Serenity Integrated Model is a model of care using specialist police officers within community
mental health services to help support service users struggling with complex, behavioural disorders.
Together they learn about the trauma and triggers that lead to high intensity behaviour, they discuss
how best to manage risk and how to ensure that the service user does not keep on repeating the
same high risk, high harm behaviour. It is demanding and intensive work but can bring significant
breakthroughs in the lives of people whose behavioural risks are likely to result in them entering the
criminal justice system or even worse, dead from accidental suicide.
In 2018 SIM Network was selected for national scaling and spread across the AHSN Network and we
have been encouraged to join the network as a potential multiagency sharing of intelligence and
alert system. It costs approx. £5,000 per annum to join the network (included in the investment
total). The additional funding for this scheme includes capacity to collectively work with stakeholder
agencies such as Police on the development of multi-agency care planning. The funding will be used
to recruit 2 Band 6 Mental Health practitioners to focus on the development of Multi-Agency Care
Plans.
Project capacity to support the delivery of the programme
The funding will be used to recruit a full time project worker to support the development of the SIM
Network, development of the Peer Support Network and development of e-consultation/e-referral
facilities.
3. The following schemes have been designed to reduce the incidence of
suicide.
Increased capacity within the Suicide Post-vention Service
The development of a Post-vention service targets the key priorities of reducing suicide risk in high
risk groups and providing better information and support to those bereaved or affected by suicide.
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The West Yorkshire Integrated Care System has confirmed funding for a West Yorkshire-wide suicide
post-vention service, based on the successful Suicide Bereavement Service in Leeds. This will have
capacity to support between 150 and 200 people per year across the region bereaved by suicide, at
any time after the bereavement and whatever the age of the person who died.
We would like to supplement the ICS offer and enable the service to employ an additional ‘postvention practitioner’ specifically to support families, friends and communities where a young person
under 25 has taken their own life. The worker would be employed and managed by Leeds Mind who
run the service, but we would negotiate co-location in Wakefield. As well as working specifically with
families and communities where a young person has died, dependent on capacity we would ask the
practitioner to work with existing services to develop and deliver preventative interventions around
suicidal thoughts, self-harm and resilience in our young people.
This would be a pilot project embedded within the ICS funded service. This has had first year of a
two year proposal confirmed with funding for 2020/21 subject to further confirmation.
Grant funding to the Samaritans
The Samaritans team in Wakefield have been active in supporting individuals, communities and the
wider partnership to respond to suicides and recent clusters. Samaritans have been supported by ad
hoc and short term funding. In order to maintain and develop the Samaritans offer to Wakefield it is
proposed that we move to a sustainable recurrent funding grant via this available resource. This
would incorporate a number of elements of delivery, including:
 Support to community groups, including training and debriefing (see note below)
 Support to post-vention service, e.g. supporting events
Piloting a Senior Suicide Prevention Practitioner in CAMHs
Following the increased investment into CAMHS crisis services in 2019/20, it is proposed that a pilot
be undertaken with a Senior Suicide Prevention Practitioner in 2020.
The post holder would work across the district with partner agencies to develop a clear and
comprehensive self-harm pathway and associated guidelines for children and young people that is
agreed by all partner agencies.
The post would also link into the suicide prevention strategy and the post-vention workers to
support the systems in the event of a suicide to co-ordinate and hold overview of risks within wider
communities and to hold overview of CYP, families and communities that may be at risk of self-harm
or suicide post a suicide in the area, what work has been undertaken to date, identify those who
require additional support and help them access this, and to escalate the need to expedite cases at
high risk of significant self-harm or suicide.
Extensive roll out of a Suicide Prevention Train the Trainer education programme
Over the past few years partners in Wakefield have invested in accredited Suicide Prevention
Training. Training courses such as SafeTALK and ASIST have evaluated well and when courses are run
are often oversubscribed. The training offered has, in the main been offered and taken up by paid
professionals. Whilst this is welcomed our work in communities affected by suicide suggests that
there is a need and demand for training specifically to be offered to community groups – these can
include a wide range of community groups from groups working to support mental health to groups
such as ‘Friends of Parks’ groups.
Working with community groups requires a flexible approach in terms of numbers trained, venues,
timings and support. In order to enable a flexible delivery this proposal advocates a ‘Train the
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Trainer’ approach. This will require non-recurrent investment to train a cohort of trainers in
Wakefield. As these are Wakefield based trainers subsequent training packages will be able to be
offered flexibly, will be based on better local knowledge and will be lower cost than externally
provided courses.
The courses that included in this proposal are:
 SafeTALK: Alertness training that prepares anyone 15 or older to become a suicide-alert helper.
 ASIST: Applied Suicide Intervention Skills Training (ASIST) teaches people to recognise when
someone may have thoughts of suicide and work with them to prepare a plan that will support
their immediate safety.
 ASK: Assessing for Suicide in Kids (ASK) is a new training package that addresses suicide risk in
children and gives people strategies and tools to identify young children at risk of suicide and
quickly gather information to assess risk and inform safety planning.
Costs associated with this are based a training provider quotation and will include:
o Delivery of training packages
o Delivery of train the trainer
o Venue and refreshment costs
o Purchasing materials for course delivery
These schemes are additional priorities that have been identified through engagement and
consultation.
Increased investment to support the delivery of physical health checks for those with serious
mental illness
The premature mortality rate for people with long term mental ill health is significant. The provision
of good quality health checks, based on the principle of making every contact count is a key area of
development. This investment will be used to raise the quality of health checks, and ensure
appropriate action is taken to address the physical health inequalities of those with serious mental
illness.
Communication and engagement support for the Mental Health Alliance
Funding will be used to ensure engagement with a wide range of partners, and ensure the voice of
service users and carers in co-designing the programme outlined.
4. The following schemes have been designed to improve support for
Children and Young People
Expansion of the Primary Intervention Team
Additional capacity will be recruited to provide increased accessibility to services and reduce the
waiting times for an assessment and treatment for children and young people. The increased
investment will allow a screening appointment for each young person followed by 2+1 brief
assessment and intervention or group work. It will also increase the volume of groups available by
allowing time within job plans to develop new resources and get feedback on these.
Expansion of the current mental health crisis provision for children and young people
Additional capacity will enable the CAMHS service to offer more intensive home based treatment in
the community to prevent further deterioration and avoid an acute or mental health hospital
admission.
Improved safety planning and care planning will lead to increased support to parents managing a
crisis at home.
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Increased investment to support the emotional wellbeing of young people
Wakefield CCG and Wakefield Council are anticipating bringing more young people back into
Wakefield from out of area during 2019/20. To support this work Wakefield Council will create 2
Emotional Wellbeing workers to support children in care at a cost of £90,000. This proposal seeks to
secure a contribution towards that cost to enable WMDC to mobilise the additional two
appointments to their EWB team during 2019/20 to support C&YP in care at the proposed
residential care settings.
Relaunch of the Future in Mind Programme
Based on the Thrive Model, a refreshed local transformation plan will be developed to ensure
Wakefield is prepared to deliver the ambitions set out in the NHS Long Term Plan.
5. The following schemes have been designed to ensure that Wakefield
is a good place to live and a good place to die with dementia
Development of a Dementia Roadmap website
Design and develop a “one stop shop” website for dementia that provides high quality information
about the dementia journey alongside local information about services, support groups and care
pathways to assist primary care staff to more effectively support people with dementia, their
families and carers.
The Dementia Website will deliver the following benefits to the GPs, primary health and social care
professionals and third sector groups that use it throughout the “Dementia Journey”.
 A one stop shop for dementia resources, reducing the time spent searching for information.
 Supports the identification and assessment of patients who present with symptoms suggestive
of dementia, signposting them to relevant resources or services
 Reassures patients and their carers/families at diagnosis and during the dementia journey by
signposting them to local resources, information and support.
 Promotes positive messages about remaining independent and living with dementia. This can
help to prevent unnecessary admission to hospital for patients with memory problems in crisis
and delay the necessity for nursing home placement.
 Provides support for carers to maintain their health and wellbeing and provide opportunities for
respite them or for the person they care for.
 Supports patients more efficiently, thereby reducing multiple / repeat appointments.
 Identifies when patients should be referred onto specialist services where appropriate.
 Helps with planning for future decisions – advance care plans, end of life care.
Supports professionals to access relevant, up to date information about Dementia including
Dementia Friendly environments, training & development and clinical standards.
Improved dementia diagnosis rate in Wakefield
The Wakefield Practice Premium Contract will include a requirement for practices to ensure
accuracy of Dementia QOF register by running the Data Quality Toolkit and reconciling new diagnosis
information provided by the Memory Assessment Service.
There is currently a variation across practices in referrals to memory assessment services compared
to expected prevalence. This project seeks to work with those practices that have a low diagnosis
rate (<65%) to identify specific actions to improve performance.
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In addition improved diagnosing of dementia in care homes will be supported through the roll out
and promotion of Dear-GP1 and DIADEM2.
Improve the quality and quantity of Advance Care Plans (ACP) for people living with Dementia in a
care home
The project will support the development of a standardised ACP template and protocol for use
across Wakefield. It will also align to the training for front line staff being supported by the West
Yorkshire & Harrogate Dementia Pilot.
Good quality Advance Care Plans provide the following benefits:
 There is greater concordance with wishes if they have been discussed, for example more
people die in their preferred place of death
 Reduced unwanted or futile invasive interventions and treatments
 Reduced hospital admissions
 Enables better planning of care, including provision by care providers
 Enhanced proactive decision making reduces later burden on family and relieves anxiety
These benefits can only be realised if high quality advanced care plans are developed, reviewed,
recorded and used. This local programme will support the regional work being undertaken to
improve access to and increase the use of Advance Care Plans.
Integrate the Alzheimer’s Society into the Connecting Care Hubs
The Alzheimer’s Society will have a visible presence within the Connecting Care Hubs and staff will
know how to refer to them. This will ensure there is:
 Increased awareness of the Society’s role amongst hub teams
 Improved signposting to support for people living with dementia
 Improved specialist dementia knowledge within the hub
 Improved communication between professionals
Identify and trial assistive technology, specifically to improve independence for people living with
dementia
Assistive technology has the potential to deliver significant improvements for people living with
dementia and their family carers including:
 Improved confidence and quality of life
 Increased independence
 Helps manage potential risks
 Supports a person living with dementia to maintain their abilities
 Helps with memory and recall
 Reduces carer stress and anxiety
The project will identify potential technologies, and pilot their use.
Improve the quality of care provided to people living with dementia through the increased use of
behaviour recording tools
The use of behaviour recording tools promotes person-centred care, reduces placement breakdown
and improves communication between professionals.
1
DeAR-GP is a case finding tool which supports care workers in care home settings to identify people who are
showing signs of dementia or confusion and refer them to their GP or healthcare professional for review.
2
DiADeM is a tool to support GPs in diagnosing dementia for people living with advanced dementia in a care
home setting.
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The project aims to identify and review existing tools, trial their use locally and support local care
providers to implement them.
Transform the design and delivery of services supporting older people’s mental health
The project will develop new community based pathways to enable rapid support in the community
to avoid an admission to hospital.
The transformation programme will deliver the following objectives:
 Ensure we have safe, person centred, needs led services that provide specialist care to older
people and their families
 Ensure services are based on the needs of the population and evidence based practice
 Ensure sustainable services that are responsive to predicted demographic changes
 More focus on prevention and health and wellbeing
 Maximise the use of technology
 Ensure the system is able to more effectively demonstrate outcomes for service users
 Services should be more efficient, demonstrate value for money
 Transformation should strengthen the relationship between healthcare providers
 Community services should be remodelled as needed to ensure they have the capacity and
capability to reduce hospital admission
 The workforce should be modelled to meet the needs of the local population, to deliver the
best possible flexibility, efficiency and skill mix, both in the community and in inpatient
services
Increasing awareness of delirium in the community and health and social care providers
The overall aim is to increase awareness of delirium so that it can be identified and treated as early
as possible including increased awareness of Delirium in primary care, acute hospitals, mental health
services, hospices and care homes.
New materials and training resources will be developed, rolled out and promoted across Wakefield
Health and Care Providers.
Priority Area 3: Elderly Care – Ensure improved co-ordination and
communication across primary care and secondary care using connecting
care plus focussing on admission avoidance for those identified as Elderly
and/or Frail
Rationale
Wakefield is expected to encounter a large population structure change within the next five years,
with the older persons grouping growing by over 11 per cent by 2020 (73,000 people), and over 22
per cent by 2021 (80,900 people). By 2031, the older population is expected to have grown by over
50 per cent, representing a population close to 100,000.
Nationally the proportion of acute emergency medical admissions contributed to by this age group
has seen a significant rise in the last 5 years from and, with ageing trends, this is expected to
increase significantly over the next 10 years. Compared with younger patients admitted to hospital,
for older people the hospital LOS is much longer, the risk of hospital-acquired complications is much
higher, discharge planning is more complex and 28-day readmission rates are much greater.
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Additionally the Implications of an ageing population are wide in terms of people living longer into
older age with a higher burden of chronic disease, an increased demand for health and well-being
services, a reduction in working age people, a reduced contribution to the economy and lower
incomes, and increased human resources for care services (paid and unpaid carers).
Within Wakefield we have 2435 active beds in our care homes (residential & nursing over 65s. These
residents in care homes are complex and more likely to be in the severe frailty category. The current
number for Wakefield on the Electronic Frailty Index (EFI) register is 3369 patients.
Better outcomes for Care Home residents
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Reduction in admissions
Reduction in attendances
Reduction in ambulance conveyances
Reduction in Beds days
Increase in End of Life patients going back to a care home
Increased number of patients in a care home with a Advanced Care Plan in place
Gaps and Actions 2019/20
The overall aim across 2019/20 is to work with Integrated Care Partnership Board partners to ensure
improved co-ordination and communication and IT infrastructure between Primary Care Home,
Wakefield care homes, secondary care, local hospices and the third sector using the workstream
priorities, connecting care plus and the frailty prevention partnership to focus on admission
avoidance for those identified as Elderly and/or Frail. This will cover the following action priorities
for the year 2019/20:
1. Develop an Elderly Care and Frailty Strategy Group to oversee the strategic development
and vision of the Elderly Care and Frailty workstream, ensuring that the ongoing work in
frailty across the district is co-ordinated to maximise the capacity of all services across health
social care and 3rd sector organisations
2. Produce a communications and IT infrastructure for the workstream that will provide a
development plan, created by partners to support the integration of the following:
a. SystmOne in care homes
b. NHS Email for care homes
3. Produce a dementia strategy to support the dementia offer across the Wakefield place. This
will involve multiple partner consultations, and the work will be led by the Elderly Care and
Frailty Strategy Group
a. Consider aligning dementia under Elderly Care and Frailty workstream
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4. Produce a connecting care evaluation, including PIC audit & interrogation to inform future
capacity and demand of services allowing partners to evaluate performance, and develop
services across the Wakefield place reflecting on capacity and demand across the system
5. Review the connecting care hub offer and align with Primary Care Home – this will allow
Primary Care Home to utilise and integrate with the Connecting Care Hubs effectively, and
work closely together on specific areas identified by partners within the Primary Care Homes
6. Use data and evidence locally to shape services – the newly formed Elderly care and Frailty
Strategy Group will interrogate and analyse relevant data to inform the future shape and
development of services across Wakefield.
7. Use the Long Term Plans, and the new GP contract as a lever to enable development of
robust service development and change
8. Access the newly developed Integrated Care System Population Health Management
dashboard. The dashboard brings together national datasets to enable insight and
investigation into national, system and place populations and the care they receive.
9. Design and implement a care home strategy, which will cover;
a. Dementia in care homes
b. Relationship with the Connecting Care hubs
c. Align with Primary Care Home moeld to provide an integrated approach to the
Enhanced Health in Care Homes offer held within the long term Plan
In addition to the above priorities the Frailty Prevention Partnership will support the Elderly Care
and Frailty workstream across 19/20 by prioritising the following areas;
1. Loneliness and isolation
2. Nutrition
3. Sensory impairment
Below is an example of current work happening in Wakefield to support hospital admission
avoidance whilst identifying frail individuals to ensure preventative measure are put in place:
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Priority Area 4: Primary Care Home - Vehicle for care integration for
registered populations of 30,000 – 50,000 in geographical communities
Rationale
Primary Care Home (PCH) is an innovative approach to strengthening and redesigning primary care.
Developed by the NAPC, the model brings together a range of health and social care professionals to
work together to provide enhanced personalised and preventative care for their local community.
Staff come together as a complete care community – drawn from GP surgeries, community, mental
health and acute trusts, social care and the voluntary sector – to focus on local population needs and
provide care closer to patients’ homes.
Primary Care Home shares some of the features of a multispecialty community provider (MCP) – but
it has four characteristics which form its distinctive identity. Its focus is on a smaller population
enabling primary care transformation to happen at a fast pace, either on its own or as a foundation
for larger models.
The four characteristics of Primary Care Home are:
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 Combined focus on personalisation of care with improvements in population health outcomes;
 An integrated workforce, with a strong focus on partnerships spanning primary, secondary and
social care;
 Aligned clinical and financial drivers through a unified, capitated budget with appropriate shared
risks and rewards; and
 Provision of care to a defined, registered population of approx 30,000 to 50,000.
The benefits of Wakefield developing and implementing the Primary Care Home model are:
 Consistent with local care integration ethos;
 Turns staff and patient frustration about communication, duplication, tribalism into energy for
change;
 Examples from elsewhere show better care, improved system efficiency, staff morale increases;
and
This priority will focus on the development of Primary Care Networks. Primary Care Home is an
extension of the role of the networks. It builds even closer alliances between general practices and
partner organisations on a localised footprint. There will be a strong emphasis on population health
management through close cooperation with Public Health and use of local population health
intelligence, with equality impact assessments highlighting where particular protected groups are
disadvantaged.
Primary Care Home aims to develop the NHS Primary Care Networks outligned within the GP
Network Contract 2019, strengthening the relationship between GP practices and community-based
health and social care providers. Developed by the National Association of Primary Care (NAPC), PCH
brings together a range of health and social care professionals to work together, providing enhanced
personalised and preventative care for their local community.
Gaps and Actions 2019/20
This priority will focus on the development of Primary Care Home. Primary Care Home is an
extension of the role of the Primary Care Networks. It builds even closer alliances between general
practices and partner organisations on a localised footprint. There will be a strong emphasis on
population health management through close cooperation with Public Health and use of local
population health intelligence, with equality impact assessments highlighting where particular
protected groups are disadvantaged.
Highlighted objectives for 2019/20 are as follows:
Develop 7 Primary Care Homes models within the Wakefield District by July 2019 affiliated to the
National Association for Primary Care, and signed up to the NHS Network Direct Enhanced Service.
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Develop rhoubust Governance within PCH
Ensure there is contracting support for PCH
Define and deliver a model for Social Prescribing
Define and deliver a model for the DES Pharmacy in General Practice
Develop workforce analytics and a workforce plan for PCH
Provide Support around data collation and analytics
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Define and deliver a Care Home Enhanced Service
Begin a full review of estates across the PCH areas
Define and begin delivery of a Leadership Development programme
Over a three year period, we will work towards the functional integration of adult community
nursing and practice nursing teams and we will do this by small steps
 We will provide the best care for patients regardless of their location i.e best teams to provide
the care for all patients whether housebound or not getting the best use out of the workforce
and skills
 It is recognised that a redefined offer for a long term condition pathway e.g. respiratory or
diabetes is required within the PCH model, which will make the best use of the skills of the
workforce. It has been identified that Integrated IAPT for long terms conditions has a potential to
be the redefined offer, to improve the healthcare outcomes for individuals, reduce the demand
on the wider healthcare system by taking a more transformative approach and integrating IAPT
within both primary and secondary physical healthcare pathways
Priority Area 5: End of Life Care Integration
Rationale
When someone’s illness is deemed as no longer curative then quality of life becomes the focus of
care. For the patient, there is only one chance to make this a comfortable and dignified phase of
their life. For the family, a poor experience can have a long term impact on their health and
wellbeing. Getting it right requires access to different types of palliative care services as well as
timely and coordinated services to ensure people die in their preferred place when the time comes.
Despite much positive progress in recent years, there are significant challenges facing the delivery of
services to the people of the Wakefield district who are in their last year of life. Challenges to service
delivery and experience include a limited awareness of and inconsistent coordination of services,
inequity of patient access and experience, and service provision that may be ‘in the wrong place or
at the wrong time’.
Improving end of life care will play an important role in delivering many Sustainability and
Transformation Plan (STP) priorities, in particular those highlighted in the Next Steps on the NHS Five
34
Year Forward View such as mental health, cancer, urgent and emergency care, as well as improving
financial sustainability. Focussing on improving care for people at end of life will:
 Improve outcomes and experience for patients;
 Improve health and care flow, reducing the pressure on ambulances, urgent and emergency care
and hospital beds through timely and appropriate responses to urgent unscheduled needs in
their usual place of care;
 Help to reduce unnecessary and unwanted admissions; and
 Improve early supported discharge to a place of care that best meets the needs of the patient,
therefore reducing the likelihood of unnecessary re-admission.
Following an options appraisal of different models of an integrated End of Life Care system, all
partners have agreed, in principle to develop and enter into an End of Life Care MoU based around
collective accountability for delivery integrated care and improving patient experience. The
governance model was approved by the End of Life Project Board in January 2018 and the Case for
Change has been approved by Wakefield CCG Governing Body in March 2018.
The following organisations have formally notified Wakefield CCG of their intention to enter into the
End of Life Care Alliance, in principle; Wakefield Hospice, The Prince of Wales Hospice, Mid Yorkshire
Hospitals Trust, Wakefield Council, South West Yorkshire Partnership Foundation Trust and Age UK
Wakefield District.
Gaps and Actions
The vision is for an integrated End of Life Care service, providing effective health and social care for
the adult residents of the Wakefield District in the last year of life, and for those who care for them,
including those who are bereaved. The system-wide ‘Right Care, Right time, Right place’ outcome is
at the forefront of the work
By developing integrated End of Life Care, combining professional expertise, knowledge and skills
and involving those at the end of life and their families, carers, we can:
 Identify those at the end of life earlier;
 Develop and deliver a coordinated advanced care plan of support that is focused around need;
and
 Help to secure better outcomes for preferred place of care.
The two key actions for End of Life Care are;
1. To develop the End of Life Care Partnership and
2. Delivery of End of Life Care work programme.
In 2019/20 integrated end of life care will be fully articulated with a robust action plan to mobilise
integration. There will be a review of the options appraisal for training and education with an action
plan to move this forwards. Continuing to embed the End of Life Care alliance within the Integrated
Care Partnership Board will ensure continued alignment with the development of the Integrated
Care Partnership.
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.It is anticipated that improved End of Life Care will impact on reducing the triple aim gap of safety
and quality, health inequalities and finance as identified below:
 Improves patient and carer experience, leading to fewer complaints;
 Reduces demand on urgent care (Ambulance, A&E, and acute admissions), and consequently
reduces non-elective spend;
 Reduces pressure on GPs by widening the responsibility for End of Life Care;
 Supports the LTC agenda in terms of principles of care, and transition to EoL services;
 Supports the MH agenda specifically in relation to dementia, and also MH conditions exacerbated
by death and dying; and
 Supports the provision of dignified care for older people with multiple co-morbidities.
Supporting the challenge of the NHS Long Term Plan (2019)
Following the publication of the NHS Long Term Plan 2019, the landscape of health and care has
begun changing significantly. The introduction of Integrated Care Systems (ICS) and closer alignment
between health and social care and CCG’s and Local Authorities has been a positive move forward in
health and care systems and Wakefield has been at the forefront of much of this work. The long
awaited Green Paper on Adult Social Care is also due to be published in the coming months and we
know that this will also bring some significant challenges however also some opportunities in how
we can work more closely together as an integrated system.
Over this period and the preceding years however, the NHS has seen a slowdown in funding
compounded by challenges in social care and public health funding, set alongside significant
increases in demand for services. This has led to decreasing performance in a number of areas
which continue to be a challenge. (As referenced earlier in this business plan a ‘do nothing’ scenario
would result in a Wakefield system wide deficit of c£237m by 2020/21. Solutions provided in the
collective STP are £192m against this system challenge). Wakefield therefore need to design new
models of care for delivering patient services, drive greater integration of services at neighbourhood
and district level and enable patients to have more choice and control over the services they need.
During the last year, we have evolved with the support of the Vanguards to maximise our efficiency
and effectiveness by working in an integrated approach with our partners. This coupled with the
development of our new five priority areas, will help us to meet the challenges set out in the NHS
Long term Plan (2019) to improve the health of people and to provide better care whilst ensuring
financial sustainability.
The financial challenge that we face is the biggest within the last generation with demands on our
resources growing faster than those resources available. Therefore, it is essential that we work
together to address the increasing financial pressure on the health and care system. Over recent
years, the Wakefield system has made major strides towards working together, which is evidenced
through the structures put in place to support joint working via the Integrated Care Partnership
Board, to successfully achieve the trajectories set out in the Multispeciality Community Provider
(MCP) Vanguard. The strong foundations of this partnership will support the Wakefield system to
36
deliver the triple challenge, allowing us to provide a greater focus on preventing ill health and
reducing health inequalities.
We aim to deliver improvements in the quality and value for money of care we provide, by
implementing the five priority areas, which will support the achievement of the triple challenge:
Priority Area 1: Lung Cancer
Understanding demand
 Cancer in West Yorkshire and Harrogate (WY&H) Alliance is a major contributor to premature
death;
 The 1 year survival rate for lung cancer is 37% (England 38%). Only 28% are diagnosed at stage 1;
 With smoking rates above the national average (15.55) at 18.6%, lung cancer is the most common
cancer in West Yorkshire and its incidence is directly related to smoking. Therefore, tobacco use
is the most preventable cause of lung cancer in the UK; and
 In 2014, there were 328 cases in Wakefield and of that, there were 219 deaths, giving a mortality
rate of 72.7%.
Estimating the benefits
The table below provides some initial high level assumptions of how lung cancer programme will
address the challenge set out in the LTP.
Improve the health of
people
Provide better care
37
There is now good evidence that earlier diagnosis can be effectively
encouraged, through a combination of screening, public awareness,
clinician education and better access to diagnostics.
Prevention – The Ottawa Model for Smoking Cessation, NICE Guidance
and Public Health England's evidence on smoking cessation
interventions suggest that supporting smoking cessation has the
greatest return on investment in terms of health gain and the
prevention of cancer.
Awareness raising – the national BCOC campaigns on lung cancer have
demonstrated that more patients are offered curative surgery. The local
campaign in South Leeds has demonstrated a reduction in lung cancers
diagnosed as an emergency presentation.
Risk identification – the city of Manchester Cancer Improvement
Partnership, a community based ‘Lung Health Check’ cancer risk
identification pilot, (which combines identification of the risk
population, an invitation to a lung heath check and the deployment of
local community based Low Dose CT scanning for those found to be at
high risk of lung cancer) has demonstrated both stage shift and more
patients being able to access curative surgery.
As a Health and Social care system it makes sense to concentrate on our
biggest killer in a whole pathway systematic approach to diagnose
Financial
sustainability
cancers earlier and that in addition there are likely to be wider health
gains in general as well as for other cancers.
Optimising pathways – lead to more timely diagnosis and potentially
removing the risk of stage shift away from cure as a result of treatment
delays.
The financial implications of achieving earlier diagnosis are less well
understood. Early stage cancer treatment is significantly less expensive
than treatment for advanced disease. However, the costs of recurrence
can be significant and should be taken into account when considering
and modelling overall cancer treatment costs. It should be
acknowledged that driving earlier stage diagnosis of lung cancer does
tend to incur costs, due to the higher level of recurrence that occurs in
lung cancer.
Although delivering earlier diagnosis for lung cancer would not be cost
saving, it could be highly cost-effective. (Saving lives Averting costs CRUK
2014)
However, as per the analysis that the Alliance undertook as part of
cancer impact on the contribution to the efficiency gap and based on
best available evidence, we believe that the overall Alliance strategy to
drive earlier stage diagnosis across all tumours to be cost effective. The
financial implications of this lung programme could be offset by savings
or reduced costs in other tumour groups where early diagnosis does
deliver greater financial efficiency gains.
Priority Area 2: Mental Health
Understanding demand
Demand for mental health support is increasing. Investment in mental health support is increasing
but not at the same rate as demand. Therefore, we need to make best use of collective resources
which will require a different approach;
• There needs to be better integration between physical health, mental health and social care
• There needs to be less duplication and waste in the system
• There is a need for greater emphasis on early help and supported self-care
• There needs to be a clear focus on supporting recovery and providing meaning and hope in
communities
• There needs to be a different dialogue between commissioners and providers
• There needs to be a single accountability structure for investment and outcomes
Areas of Focus
In the first instance, the Mental Health programme will focus on creating an infrastructure to deliver
future transformation; establishing the Alliance, ensuring there is a common understanding of local
challenges and identify the key local priorities, agreeing a three year work plan and testing the new
way of working by developing a new Personality Disorder Pathway involving all partners.
38
Estimating the benefits
The table below provides some initial assumptions of how Reimagining Mental Health Care will
address the challenge set out in the NHS LTP.
By the end of Quarter 2 2019/20 we will have more detail about the precise financial position in
relation to Mental Health generally and the Personality Disorder pathway specifically.
Improve the health of  Earlier identification of mental health problems will enable support
to be provided to a wider population
people
 Pathways will promote prevention of mental illness, self-care , early
intervention and recovery
Provide better care
 Closer partnership working will reduce the gaps between services
 Better care coordination and shared records will reduce duplication
 Reduction in demand for crisis care, due to focus on early
intervention and prevention
 Evidence based care, using best practice as standard
 Building on Wakefield’s expertise- recovery, creativity, forensics,
vanguards
Financial
 Key focus will be on achieving investment in line with Mental Health
Investment Standard
sustainability
 Savings will be based on the Mental Health Five Year Forward View
assumptions.
In order to meet the growing demand for mental health support the
Alliance will need to:
 Prioritise investment into high impact areas
 Maximise the outcomes delivered per £ invested
 Identify efficiencies across the system and reduce duplication
 Identify where things can be done more efficiently at scale e.g.
across West Yorkshire
 Evaluate their impact to understand where savings are being made
across the health and social care economy
 Maximise opportunities for attracting additional investment into the
District e.g. through the WY&H Health & Care Partnership
It is expected that the implementation of a Personality Disorder Pathway
will deliver savings in the following areas:
 Reduced MH admissions
 Reduced A&E attendances
 Reduced ambulance call outs
 Reduced S136 detentions
 Reduced duplication
Scoping and design work in Q1 and Q2 will identify the precise savings to
be made during 2019/20, which will then be part year effect.
Priority Area 3: Elderly Care
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Understanding demand
 Being able to know that we will receive health and care if and when we should need it matters to
all of us, at any age, but it is all the more salient as we get older. Many people in their sixties and
seventies enjoy good health and do not need any additional support with daily living, but as we
move into our ninth decade and beyond this becomes less common and more of us will need
help;
 By the time we reach our early eighties only one in seven of us will be free of any diagnosed long
term health conditions and, once we reach the age of eighty five, eighty per cent of us will be
living with at least two. The same pattern can be observed when it comes to care needs: by our
late eighties, more than one in three of us have difficulties undertaking five or more tasks of daily
living unaided;
 The numbers of people aged 85+ in England increased by almost a third over the last decade and
will more than double over the next two decades;
 By their late 80s, more than one in three people have difficulties undertaking five or more tasks
of daily living unaided and between a quarter and a half of the 85+ age group are frail, which
explains why it is people in this oldest cohort who are most likely to need health services and care
support;
 Life expectancy continues to increase in the UK, but this increase is not necessarily extra years
spent in good health and free of disability. Estimates of life expectancy suggest that, on average,
a man aged 65 in the UK will live a further 17.8 years, but that will include 7.7 years of poor
general health and 7.4 years with a limiting chronic illness or disability towards the end of their
life;
 On average, a woman of 65 will live a further 20.4 years, but that will include 8.8 years of poor
general health and 9.2 years with a limiting chronic illness or disability. For Wakefield men at 65
can expect 17.7 years of life, but this will include 6.9 years of poor general health and 10.3 years
with a limiting chronic illness or disability. For Wakefield women at 65 can expect 20.4 years of
life, but this will include 7.8 years of poor general health and 13.0 years with a limiting chronic
illness or disability;
 The risk of dementia increases with age. In 2012 around 800,000 people in the UK were living
with some form of dementia. In Wakefield district we estimate that the number of people over
the age of 65 with dementia will rise from 3,700 in 2010 to 6,900 by 2030;
 Over time Wakefield has seen an improvement in diagnosis rates for dementia (from an
estimated 37% of people with dementia in 2008 to 53% in 2014). We estimated that 66% of those
with dementia over 65 years have been diagnosed. However this means that a third of people
with dementia have not been diagnosed;
 Frailty is now recognised as a condition which affects many, but not all, older people reducing
their ability to recover when challenged by sudden, unexpected life changes. These changes can
be physical like an infection or fall or psychological like the bereavement of someone close.
Frailty can lead to multiple hospital visits and a rapid decline in health and well-being;
 Care Homes place a significant impact on primary and secondary care. In Wakefield we have 58
residential and nursing homes over 65`s with a bed capacity of approx. 2,000. Most of the
attendances and admissions (three times more commons) are linked to falls, respiratory,
pneumonitis and dementia;
 Care Homes residents in their final years of life are more likely to be frailer and have more
emergency admissions that older people who live alone; and
 Many people who live in care homes are close to end of life, this is when hospital activity typically
increases.
Area of Focus
40
In the first instance, the Elderly Care working group will focus on the areas that we recognise will
contribute more specifically at this stage to the FYFV. These may include:
 Training in Care Homes – EOL and Dementia Increase the number care home residents with ACP
and EOLC plans in place – based on submission to the New Model of Care Vanguard calculations
in 2020/21 £2.2m saved, at a cost of £0.9m, £1.3m net saved and 101% return over 5 years;
 Focus on the Dementia Pathway - Develop a model and agree how services could change to meet
what will be an increasing demand in the future ,and how that model fits with the connecting
care plus /hub model /primary care home;
 Telemedicine roll out on an additional 6 care homes with a potential ROI of 121%, £9,447 per
home (based on Airedale Modelling) with a further £61k investment; and
 Concentrate on moderate to severe frailty without losing the momentum on mild frailty.
As the Elderly Care work evolves, these areas will be reviewed and refreshed when more work is
undertaken with the group.
The Elderly Care work steam will work collaboratively all other Priority work streams, but with a
particular focus on the EOL, Primary Care Home and Mental Health priority work streams in the first
instance.
By the end of Quarter 3 2019/20 we will have a greater understanding locally of the following:
Improve the health of people
Provide better care
Financial sustainability
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 Training of staff to co-develop deliver tailored care plans with
patients will result in:
 Improved end of life care
 Higher patient satisfaction with level of care provided
 Improved patient management, including long term conditions
 Increased consistency of care provided
 Increased accessibility of care through telemedicine
embedded in more homes results in:
 Increased feeling of safety
 Increased independence
 Improved electronic communications
 An improved general life experience for residents in care
homes and tenants in supported living facilities, as well as
better health
 Increase in the proportion of deaths in place of usual
residence
 More efficient and effective partnership working to achieve
joined-up care
 One GP practice one care home model
 A reduction in the need for urgent health care and hospital
admissions for people in care homes
 A reduction in the number of ambulance call outs for falls
 Financial benefits for CCGs in year through a reduction in
ambulance call outs, therefore a reduction in A&E
attendances, admissions and bed days.
 ROI of 121% based on Airedale modelling. Reduced
unnecessary GP and ambulance call-outs, patients’ lengths of
stay in hospital whilst also supporting care outside hospital,
including early discharge.
 A further investment of £61k for the roll out of 8 additional
Airedale Telemedicine across Wakefield in 18/19
 The actual savings for care homes in 2016/17 were £1.647m
at a cost of £959k, so net savings of £688k - the 5 year
forecast at the start of March 18 suggests for 2020/21 £2.2m
saved, at a cost of £0.9m, £1.3m net saved and 101% return
over 5 years
Priority Area 4: Primary Care Home
Understanding demand
 One of the biggest challenges facing general practice is the workload placed on staff and
practices. GP workload has grown hugely, both in volume and complexity. Research samples
show a 15 per cent overall increase in contacts: a 13 per cent increase in face-to-face contacts
and a 63 per cent increase in telephone contacts. While the demand for general practice services
is increasing the workforce available to provide these services is not;
 A growing and ageing population, with complex multiple health conditions, means that personal
and population-orientated primary care is essential
 Population changes account for some of this increase, but changes in medical technology and
new ways of treating patients also play a role;
 Wider system factors have compounded the situation. For example, changes in other services
such as community nursing, mental health and care homes are putting additional pressure on
general practice. Communication issues with secondary care colleagues have exacerbated GP
workload;
 Increase in workload has not been matched by a transfer in the proportion of funding or staff;
 Integrated IAPT LTC - 70 per cent of people with medically unexplained symptoms (MUS) will also
suffer from anxiety and/or depression.
Areas of Focus
In the first instance, the PCH working group will potentially focus on areas that we recognise will
contribute more specifically at this stage to the FYFV. These may include:
 Embedding of the national GP Network Contract
 Integrated working between practice and district nurses
 Clinical Pharmacy in General Practice - build on this with Community Pharmacy as part of the GP
Network Contract requirements
 Physio Line
 Integrated IAPT model focusing on Long Term Conditions and initially the respiratory pathway
 High intensity users of services
As the PCH work evolves, these areas will be refreshed when more work has been undertaken by the
group. The starting point for PCH is for groups of practices and partner services to agree what can
be improved to make more patient centric care.
Estimating the benefits
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It is anticipated that Primary Care Home will impact on reducing the triple aim gap as identified
below:
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Making more efficient use of what we have both capacity and financial resources;
Reducing staff burnout and turnover;
Focus on better care for people and better health for the population the staff all care for; and
Continuity, communication and shared objectives.
Outcomes
Developing the Primary Care Homes in Wakefield is expected to achieve the following outcomes:
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Improving the health of populations;
Improving the individual experience of care;
Reducing per capita cost of care;
Improving the experience of providing care; and
Increasing joy and meaning for the workforce.
The objective of Wakefield clinical commissioning Group is to have:
High quality list-based general practice in Wakefield thrives at practice level, collaborates effectively
and efficiently through Primary Care Home, plays its full leadership role at health and care system
level and is responsible for its own resilience and development.
The table below provides some initial assumptions of Primary Care Home of the potential areas
which will address the triple challenge set out in the GPFYFV. Designing a primary Care Home will
ensure patients receive the right care in the right time at the right place.
By the end of Quarter 3 2019/20 we will refresh these assumptions when more work has been
done by the group and following engagement with the pilot site champions to identify areas of
development. The PCH model will be driven by primary care, who will determine the areas that
require improve to deliver and enable future sustainability.
Improve the health of
people
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Provide better care
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CPGP model aims to improve quality outcomes for better health by
targeting medication reviews on polypharmacy, high anti cholinergic
burden and patients at risk of acute kidney injury.
Integrated IAPT LTC - integrate IAPT therapists, qualified to support
people with long term conditions, into physical health care pathways
in order to improve patient outcomes.
The CPGP model is focused on delivering quality outcomes to
patients, implement cost-effective prescribing and institute robust
policies within the sphere of medicines management in general
practice. Significantly, for robustness and longevity, there is a suite of
data capture tools that will record outcomes from pharmacists and
pharmacy technicians working in this model.
Integrated IAPT LTC - potential to improve the healthcare outcomes
for individuals, reduce the demand on the wider healthcare system
by taking a more transformative approach and integrating IAPT
within both primary and secondary physical healthcare pathways. In

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
Financial sustainability

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addition, taking a more holistic approach to an individual’s care is in
line with both national and local priorities e.g. the Sustainability and
Transformation Plan and the Multispecialty Community Provider
Vanguard programme. NHS England state that of all the people
suffering from long term physical health conditions (LTCs): Two thirds
will have a co-morbid mental health condition, most likely to be
anxiety and/or depression
The Integrated IAPT services in Wakefield would need to ensure that
they are specifically targeted so that the right interventions are given
at the right point of the LTC/MUS pathway – e.g. primary,
community, secondary care etc. This is to ensure that patients get
the best possible outcomes, but also so that the limited resources
available are used to best effect.
Physioline: This will improve patient access to the right clinician
more quickly to commence self care support for MSK patients if it is
further refined to allow referral by GP reception staff or self-referral.
In the small pilot in 2017-2018 data collated has illustrated 41%
reduction in first appointments to community physiotherapy & 34%
reduction in follow up appointments through access to Physioline
services.
Integrated working with district and practice nurses : potential to
improve the quality of care provided to the local population by
working together to deliver person centred care e.g. would care
pathway
High intensity users – reducing frequent user activity of GP contacts
and other areas, freeing up front line resources to focus on more
patients and reduce costs. It will use a health coaching approach,
targeting high users of services and supports the most vulnerable
patients within the community, to flourish, whilst making the best
use of available resources.
CPGP: a GPFV initiative basing pharmacists and technicians (including
some of the CCG medicines team) in practice federations to reduce
prescribing costs, improve prescribing quality and safety and extend
the capacity of the practice healthcare team. The pilot service has
generated c£450k of prescribing savings for the CCG since October
2017. The CCG contribution will reduce over three years with
practices taking over an increasing proportion of the cost.
Integrated IAPT LTC - As a headline figure, psychological
interventions could save 20% of physical healthcare costs. A more
realistic figure for Wakefield has been identified by improved patient
outcomes leading to reduced ambulance call outs, A&E attendance
and emergency admissions. Evidence from Layard and Clark (2015)
evidenced a reduction in healthcare use per COPD patient per 6
months to be worth £837 across secondary care (A&E and acute
admissions). Therefore, £220k saving to WCCG. This is based on 271
people “recovering” from September 18 to March 19.
Physioline – the CCG already commissions a community MSK service
and this is a sustainably funded model of care as the reduction in
referrals to community would offset the costs of delivery of the
extended pilot in 18/19. Costs of delivery would be £49,440 and
estimated savings would be based on a 23% reduction in spend on
physio for the 5 GP practices taking part in the pilot (which equal
approx. 15% of the Wakefield’s GP registered population) the net
saving for Physioline for this year is £52,000.
Priority Area 5: End of Life Care Integration
Understanding demand
 Each year there are around 3,200 deaths in Wakefield. The main causes of death are cancer
(28%), circulatory disease (26%) and respiratory disease (16%). By 2040 deaths per annum in
England and Wales are projected to rise by 25.4%. For Wakefield this equates to 4012 deaths per
annum;
 An estimated 2,200-2,600 people may need palliative care in Wakefield each year, however not
everyone needing palliative care will require end of life care;
 It is estimated that 1% of a GP practice population will die each year. Not all of these however
will be categorised at end of life, some will die from accident and injury;
 In 2016, 47.6% of people in the district died in hospital and it is estimated nationally that 30% of
inpatients in acute hospitals at any time will be in their last year of life;
 Hospital Costs are the largest cost elements of EoLC within the final 3 months averaging at over
£4,500. The bulk of costs are due to emergency hospital admissions in last few weeks of life; and
 Approximately 40% of people in the last year of life use some form of Local Authority funded
social care.
Estimating the financial benefits
The table below provides some initial assumptions of how integrated EoLC will address the triple
challenge set out in the FYFV. Designing an integrated EoLC system will ensure patients receive the
right care in the right time at the right place. It is anticipated that improved End of Life Care will
impact on reducing the triple aim gap of safety and quality, health inequalities and finance as
identified below:
Improve the health of
people
Provide better care
45
 Earlier identification of those at the end of life and Advance Care
Planning (ACP) will improve patient and family satisfaction and
reduce stress, anxiety and depression in surviving relatives.
 Earlier identification of those at the end of life and ACP will
improve outcomes and experiences for patients and will reduce
the number of formal complaints.
 Better care coordination and shared records will help secure
better outcomes for preferred place of care and death.
 In 2016, 47.6% of people in the district died in hospital and it is
estimated nationally that 30% of inpatients in acute hospitals at
any time will be in their last year of life.
 Improves patient and carer experience, leading to fewer
complaints.
 Reduces demand on urgent care (Ambulance, A&E, and acute
admissions), and consequently reduces non-elective spend.
 Reduces pressure on GPs by widening the responsibility for EoLC.
Financial sustainability
 Supports the LTC agenda in terms of principles of care, and
transition to EoL services.
 Supports the MH agenda specifically in relation to dementia, and
also MH conditions exacerbated by death and dying.
 Supports the provision of dignified care for older people with
multiple co-morbidities.
 Integrated EoLC will reduce demand on urgent care (Ambulance,
A&E, and acute admissions), and consequently reduce nonelective spend.
 Improved use of EPaCCS, by all those involved in a person’s care,
will generate financial savings.
 Hospital Costs are the largest cost elements of EoLC within the
final 3 months averaging at over £4,500. The bulk of costs are
due to emergency hospital admissions in last few weeks of life.
 Approximately 40% of people in the last year of life use some
form of Local Authority funded social care.
 National modelling indicates that if access to community-based
EoLC improved AND emergency admissions reduced by 10% AND
average LoS following admission reduced by 3 days… £104
million nationally could potentially be redistributed to meet
peoples preferences for Preferred Place of Care.
 Economic evaluation of Electronic Palliative Care Coordinated
Systems (EPaCCS) indicates financial savings can be made where
these systems are in place to share EoLC records and ACPs –
recurrent savings after four years c£270k for a population of
200,000 people.
 By the end of Quarter 3 2019/20 we will have a greater
understanding of the impact of integration locally with clearly
articulated targets and financial benefits modelling.
Governance of Integrated Care in Wakefield
The monitoring and progress of the Connecting Care + Business Plan will be overseen by the
Wakefield Integrated Care Partnership Board and will be embedded within the current governance
structure as outlined below. Regular quarterly updates will be provided to Wakefield’s Health and
Wellbeing Board to provide assurance to the HWB that progress is being made on this key priority
for the Health and Wellbeing Board.
46
(Diagram 1)
Formal quarterly reports will come to the Integrated Care Partnership Board to highlight progress of
our business plan, alongside more regular updates on specific developments if required to seek the
Board’s assistance to unblock any challenging issues that have not been able to be resolved without
Chief Officer intervention.
Key Enablers for Connecting Care + Business Plan 2019-2021
Workforce Transformation Plan – Workforce working as ‘One Integrated
Team’
We value our workforce asset in Wakefield, knowing that retraining, retaining and recruiting to our
health and social care workforce is our key objective. We know that the workforce asset is at the
heart of our ability to deliver person centred and community centred approaches here in Wakefield.
How we will achieve the ‘One integrated team’ in Wakefield which will support the Connecting Care
+ priorities is detailed in our Workforce Transformation plan (and strategy), and this is a cumulative
effort of over 2 years of partnership working in Wakefield - an inclusive approach with our health,
social care and voluntary, community and social enterprise sectors. The work we have done together
has been showcased as a national exemplar and we have continued to benefit from access to
expertise from regional and national workforce leaders who support us in shaping our place based
plans.
As collaborating partners in a Connecting Care + alliance, the strategic leaders are committed to joint
workforce planning based on in depth analysis of our collective people resources and assets. To
make this happen, staff will be empowered through a model of distributed leadership, where they
47
take responsibility for their performance and hold each other to account. With this as our ambition,
the Workforce Transformation steering group created 5 key priorities as part of our Workforce
Transformation aspiration – and these five priorities will support Connecting Care + to continue to
work as ‘One integrated team ‘ - creating an ICS (integrated care system) and tackling the gaps in
Wakefield’s health and social care provision.
With real time information on the skill mix and workforce demographic across all levels of care
including general practice and other independent contractors we will be best placed to plan and
then execute our strategies. Our intention through the life of this business plan is to grow the
optimum workforce, thereby supporting the strategic objectives and the five listed priorities, all of
which warrant vibrant change programmes, continued skill mix and integrated working practices and
continuous improvements in care pathways.
Our published Workforce Transformation Strategy, signed off by the partnership, supports the
business plan priorities and warrants all partners to align their own organisational strategies to
ensure targeted improvements in our population’s health outcomes whilst making optimal use of
resources.
Dynamic health needs assessment identifies potentially unwarranted variation in care and our
workforce plans address inequalities in outcomes, spend and healthcare interventions. Whether we
are seeking to deliver the best in lung health, mental wellbeing, frailty assessment and management
or a compassionate end to life our staff will be supported so that they understand the system they
are working in, adopt a shared culture of compassion, have a universal commitment to citizen
empowerment and to making every contact count and are executing their roles in teams with a
mixed suite of skills and competencies. Below is our strategy ‘plan on a page’ – highlighting the key
elements of our approach.
48
Workforce Transformation Strategy - Our Five Key Priorities:
The overarching aim of the Connecting Care workforce transformation strategy is to ensure we
have a confident, motivated workforce with the right skills, values & behaviours engaged and
supported to deliver the connection Care Vision, Strategic Objectives and Plans whilst maintaining
financial stability
The initiatives detailed below are captured in full detail in our Connecting Care Workforce
Transformation Implementation plan
The Five Key Priorities:
1.
2.
3.
4.
5.
49
Workforce Strategy and Planning
Enhancing and Growing Systems Leadership
Growing Talent and Securing Resilience
Redesign – New roles, new ways of working
Staff Engagement (Culture Change)
Communications and Engagement Plan
Communications, engagement and equality are a key enabler in the delivery of the Connecting Care+
Business Plan which is overseen by the Integrated Care Partnership Board, and overall led by the
Health and Wellbeing Board. The Communications, Engagement and Equality Plan needs to reflect:
 A district-wide communication and engagement partnership that maximise best use of resources
and skills;
 Patient and public voice on relevant service changes with feedback gathered to support the
programme of work; and
 The delivery of any communication in-line within the workstreams of the Business Plan.
The Plan will support the workstreams and other enabling support elements of the overall ICP
Business Plan, and work alongside these to ensure clarity on which elements of the five priority
areas and enablers require support. The Plan will be delivered by our district-wide Communications
and Engagement Working Group, in line with our agreed engagement and communication objectives
and principles, as below:
 Be open, honest, consistent, clear and accountable;
 Ensure communications and engagement activities are accessible to all audiences;
 Give clear, accurate and consistent messages, linked to the overall Connecting Care+
programme’s visions and values;
 Ensure planned, timely, targeted and proportionate communication and engagement;
 Provide cost-effective, high quality information – maximising our resources;
 Work in true partnership with other agencies, stakeholders, patients/service users, carers and
patient representatives to reduce health inequalities and improve health outcome;
 Lead by example and learn by what we do – both by what we do well and what we can improve;
 Provide a variety of innovative, creative opportunities to communicate with people and for
people to engage with us; and
 Use best practice methods and encourage our member practices to adopt these principles.
Note: The above objectives and principles were taken from our 2017 MCP Communications and
Engagement Plan.
The Communications, Engagement and Equality Plan will be refreshed on an annual basis by the
group to ensure we are working flexibly in-line with the Connecting Care+ programme as it develops.
Progress against the Plan will be tracked through both the workstreams outcomes and fed back to
the Integrated Care Partnership Board.
Technology Plan
The Connecting Care + vision is to create a ‘digital’ health and care community that shares
information and knowledge, communicates, plans and collaborates in ways that helps the citizens
50
across the district to receive the highest possible quality of care, supported by the citizen having
access to the information needed to help them self-care.
It is expected that the Connecting Care + model will build upon this vision to provide digital delivery
of services that support improved health and well-being, firstly across the priorities identified in the
Connecting Care + model on a local place basis and then more widely across the STP footprint as
digital health services mature, recognising that not all citizens will choose or be able to utilise digital
services.
The Connecting Care + model should acknowledge and ensure that the benefits of the wide-scale
use of key information systems, in particular SystmOne, is maintained and integration or
interoperability across the model should incorporate and build upon that of the earlier Connecting
Care programme to ensure that, with appropriate consents and safeguards, both pseudonymised
and identifiable data can be shared and used by care professionals and citizens to better support
health and well-being.
In particular the model will build upon the personal integrated care file “PIC” developed and used in
the connecting care hub teams where information is shared appropriately across all partners and, as
an example, electronic referrals to the service by GPs can be extended on a wider scale.
It is recognised that some digital enablers perhaps including a Mid Yorkshire Hospitals Electronic
Patient Record or regional shared health and care record will be best developed at an appropriate
scale across all health and care partners; the place-based Connecting Care + model should be
developed to support this wider integration.
The delivery of the model will ideally require that we separate the underlying technology from
future organisational changes as the connecting care + model develops. To achieve the successful
delivery of connecting care + it is essential that key elements of technology are designed and
51
implemented to a place-based ‘architecture’. This means that some decisions will be made for
Connecting Care + rather than at an individual organisational level.
Implemented correctly there are substantial benefits to be gained from the use of Online Services
and Unified Communications both for health and care professionals and between professionals and
citizens to support timely and effective delivery of services.
We will leverage the benefits of using national ICT services delivered by NHS Digital and its partners;
as examples; HSCN, NHSMail, Cyber Security, NHS WiFi, GP Online and Online consultation, 111
online etc.
At the most simplistic level, information and knowledge will be shared securely for the right care in
the right place at the right time through:
1. Enhanced communication and collaboration for people and systems;
2. Investment in technology linked to business and clinical objectives across the Connecting Care +
model, the CCG, its partners and service providers; and
3. Innovation that will lead to the improvement in the quality of services and better outcomes for
citizens.
Estates
Over the last 2 years a wide range of staff from Mid-Yorks Hospital Trust (MYHT), Wakefield
Metropolitan District Council (WMDC), Age UK Wakefield District (Age UKWD) and Carers Wakefield,
have been co-located in the Connecting Care Hubs at Bullenshaw (Hemsworth), Waterton (Lupset
and Civic Centre (Castleford).
During April to November 2017, significant phase 1 accommodation changes and improvements
were made to approximately 20% of the building space at both Waterton and Bullenshaw, to enable
other organisations to have a presence in order for them to join the newly re-designed multidisciplinary teams (MDT’s). These new MDT’s and care co-ordination arrangements commenced in
4th December 2017, whilst at the same time, Mid Yorkshire NHS Hospital Trust (MYHT) ‘MY Therapy’
service was co-located with Adults Integrated Care, Social Care Direct team at Wakefield One.
Currently the MDT’s and new care co-ordination arrangements in both Bullenshaw and Waterton
Connecting Care Hubs include support workers from Age UKWD, Carers Wakefield, Mental Health
Navigators, Community Matrons, OT’s, Physiotherapists, Dieticians, Therapy Support Staff, WMDC
Adults Social Workers and Care Co-ordinators, WDH and Pharmacists.
An Intermediate Care estates review is required to support winter planning for 2019, which will need
to be completed by winter 2019.
Health and Housing
52
Poor housing affects people’s physical and mental health. The health of older people, children,
disabled people and people with long term illness is at greater risk from poor housing conditions.
The home is a driver of health inequalities.
The right home environment will protect and improve health, enable people to manage their care
and health needs and to remain at home. This greatly impacts on delaying or reducing the need for
primary care and social care interventions, preventing hospital admission and supporting timely
discharge from hospital to home.
The Five Year Forward View and the Next Steps on the Five Year Forward View highlight the
importance of the role of housing in improving health and wellbeing and that the right home
environment is essential to health and wellbeing. It is widely evident that addressing wider
determinants affects the demand for primary and acute services. Therefore, working with Housing
clearly aligns to some of our key priorities within our Health and Wellbeing Plan and contributes to
reducing both the care and quality and health and wellbeing gaps.
Enabling the right home environment for health and wellbeing is complex and requires people,
communities and organisations to come together. The Building Research Establishment (BRE)
estimates that the cost to the NHS nationally of poor housing for those over the age of 55 is about
£624m per year. On a local level the BRE estimate that the cost of treating accidents and ill-health
caused by hazards in private sector housing is £4m per year and by mitigating these hazards it would
save the NHS £3.7m. The most common housing condition hazards for private sector housing in the
Wakefield district are trips and falls and cold homes.
With this in mind there is also a clear alignment to addressing the finance and efficiency gap for the
Wakefield health and care system and working towards a sustainable future focussed on prevention.
On the 9th March 2017 the Connecting Care Partnership agreed to create a Housing, Health and
Social Care Partnership group (HHSCP) to sit under the wider architecture of the Health and
Wellbeing Board. The Partnership includes representation from Wakefield Clinical Commissioning
Group (WCCG), Wakefield Council, WDH, fire service and the voluntary and community sector.
To take forward the work, a seconded post of Associate Director Housing and Health Transformation
was agreed between WCCG and WDH.
The HHSCP agreed to focus on the following areas:
1. Development of the reablement support service’s on a 24/7 basis through the inclusion of
WDH’s Care Link technology, home visiting and response service as part of the 6 week plan.
Telecare is now offered as a standard part of the reablement service, provided through WDH’s Care
Link service free of charge to the patient for the duration of their reablement. As a result, many
patients have continued with the service post reablement, providing them with ongoing support in
their home to maintain independence. We are now extending this offer to include the Care Link
responder service.
A challenge has been to raise awareness of the Care Link service and the associated benefits. To help
address this, all fire crews have received training on technology enabled care and this has generated
further referrals to the service via the Safe and Well Scheme. The Care Link team has also had
frequent attendance in the foyer at Pinderfields Hospital to raise awareness with patients and NHS
staff.
53
As part of the Age UK Hospital to Home transport service, patients also benefit from the installation
of Care Link telecare in their home to provide ongoing 24/7 support, free of charge for up to one
month.
A Care Link home responder is also provided as part of the Hospital to Home service. From the
current Care Link service users, ambulance call outs have been mitigated in up to 42% of falls
incidents.
2. Promoting social inclusion in WDH independent living schemes to avoid tenancy terminations
for residential or nursing care and to reduce hospital admission and GP appointments through
the extension of the Vanguard work and the development of wellbeing drop-in facilities.
Following the success of the Vanguard work at WDH’s Croftlands Extra Care Scheme where tenancy
terminations to residential care were eliminated, six more housing schemes have been identified to
take forward the Vanguard work.
As part of the resource for winter planning, guest flats within WDH’s independent living and extra
care schemes will be accessible for patients who are ready for hospital discharge but are unable to
return to their own home immediately.
3. Promotion of grant funding to tackle fuel poverty and poor housing conditions in the private
sector.
Wakefield Council Strategic Housing have delivered training and raised awareness to health and
social care teams on fuel poverty and the grants available for home improvements. This has resulted
in referrals for the Council’s Fuel Poverty Fund, which provides heating grants for vulnerable and fuel
poor households.
A scheme to provide external wall insulation grants to fuel poor, hard to treat households at
Castleford commenced in October and aims to help 76 households.
The Council have been promoting their interest free home improvement loans and other externally
provided offers through an ongoing programme of social media and events.
4. Develop an innovative housing scheme that promotes Connecting Care
WDH has identified a site to build a new independent living scheme. Partners have agreed to
collectively work on the design of the scheme and to consider the service provision and community
facilities that will form part of its development.
Options for including rehabilitation and reablement services within the scheme are also being
considered. The Local GP practice and Health Champions have also been consulted and have
expressed an interest in running some of their Health Champion activities from the scheme.
5. To input into, and to oversee the delivery of, the Local Estates Strategy for the district to ensure
that it is able to facilitate the delivery of the Wakefield Health and Wellbeing Plan.
Estates and housing are key enablers to deliver the Wakefield Health and Wellbeing Plan and it is
important that as a system we ensure that we have the health and care infrastructure in place, or
planned for the future population need. This needs to take into account addressing current issues
54
and preparing for potential future issues, in a manner which not only ensures health and care
provision for the needs of the population but which also takes in to account the clinical services
strategy for the district.
Whilst there is a current interim Local Estates Strategy, this now needs to be refreshed to ensure
that it encompasses the entire health and care sector and is fit for purpose to help deliver the Health
and Wellbeing Plan.
This needs to take into account the refreshed Joint Strategic Needs Assessment, existing strategic
plans such as the Health and Wellbeing Plan, the GP Forward View and organisational asset
management plans. It will also need to align to the refresh of the Local Plan (within the Local
Development Framework) in order to ensure that we are planning for a sustainable health and care
system for the Wakefield district. It is anticipated that this refresh will also fit with the timeline of a
potential refresh of the Health and Wellbeing Plan.
In addition to the priorities, set projects have emerged through the discharge to assess work. It has
come to light that housing advice and assessment is something required at the start of a patient
journey, to avoid a delayed discharge.
From April 2018, a Housing Support Coordinator (HSC) will be based within Fieldhead Hospital. The
HSC will work directly with patients and their families and hospital staff to identify and resolve
housing issues that are a potential barrier to discharge. They will signpost and arrange for low level
support to assist with the transition from hospital to home in order to prevent readmissions.
The HSC will advocate for the patient and the hospital on other housing issues, such as repairs and
adaptations and could act as an independent mediator where family disputes occur with the hospital
regarding the discharge from hospital.
The emphasis is on preventing, reducing and delaying with the intended outcomes being:






reduced delayed transfer of care;
reduce risk of readmission;
Reduce risk of premature admission to residential care;
improved wellbeing;
extended independent living at home; and
increased resilience and ability to manage future life change.
There are also plans to place a HSC within Pinderfields Hospital to work alongside the social work
discharge team.
Next Steps
The HHSCP is seen as a key enabler to delivering new models of care and has set out a work plan
which aligns to the wider priorities of the Health and Wellbeing Board. The plan’s focus is on 4
strategic outcomes and 1 operational;
Strategic:
•
55
Reduced pressure on 999 calls and A&E attendance

Reduce housing related delayed discharge through the provision of warm and healthy
homes

Provide Housing related support tackling the health impacts of poverty and integrate into
new models of care

Improved aspirations for young people living in our neighbourhoods.
Operational:

Ensure housing, health and social care legislation and policy is considered and appropriately
disseminated.
The partnership have also taken an important role in being involved in the consultation on the
refresh of the Local Plan which will set out where land for housing developments will be allocated
until 2036. As a Housing Zone area Wakefield already has considerable housing development,
primarily spread across three key sites in the district and the refreshed plan will set out further
significant growth. It is critical that the Wakefield Health and Care Sector understand the impact of
this and contribute to the technical consultation in order to ensure that future provision of health
and care is planned for in the right way, in particular through new models of care, to improve
outcomes for current and future population need. The partnership will have a role in responding to
this, mobilising a partnership approach to meeting demand and influencing the design principles we
expect of developers in building lifetime homes
56
New Model of Care Board Priority Action Plans
Lung Cancer
Priority Area 1: Lung Cancer
Health & Wellbeing Priorities: Strengthening the role and impact of ill prevention & Ensuring a healthy standard of living for all
Action
Target
Outcome
Milestone
Owner
Resource
1.1: Optimising Smoking Cessation Support -Impact reduction in smoking prevalence, reduction on re-admission rates and hospital mortality (Ottawa
data)
Work with Yorkshire
Offer smoking
Increased quit
10th June 2019 to
Chris Hunton/Hazel
Funded by YCR grant
Smokefree, Wakefield
cessation
rate
November 2019
Taylor
Ongoing
Council, Practice
support at the
Managers and Yorkshire time of the LHC
Cancer Research to
deliver on site smoking
cessation immediately
after LHC at Church
View Medical Centre
57
.2: “Push and Pull” Symptom Awareness Campaigns and Community Engagement Events- Impact: Reduction in cancers diagnosed as an emergency
presentation, more cancer diagnosed overall and more people offered curative surgery (earlier stage diagnosis).
1.2.a - Adopt and plan
campaigns using the
national cancer
communications
materials and smoking
campaigns (Stub it Out,
Keep it Out, Breathe
20/25);
58
Localised
communications
about LHC/LDCT
and wider
Wakefield Lung
Health
Awareness
Earlier diagnosis
and symptom
awareness
Proposed new date:
May/June 2019
Advertising = £7K
Lisa Chandler, Public
Health Team and Chris
Hunton – Wakefield
Project Manager
Community
Engagement Link vias
Nova – Natalie Jones
Community Engagement Link = £36K
Funded from WY&H CA funding
1.2.b - Deliver the
cancer and smoking
campaign in
appropriate timescales
across 2019/20.
Proposed new date:
End of December
2019
1.2.c- Delivering the
Cancer campaign to
residents in Wakefield
Healthy Futures
Communications Team,
Wakefield CCG
Wakefield
Communications and
Engagement Capacity
(Enabler)
1.3: Risk Identification in Primary Care to Promote Direct to Low Dose CT (LDCT) Scanning- Impact: More lung cancers diagnosed overall and at an earlier
stage offering surgical treatment
Work with Conexus to
deliver Lung Health
Checks (LHC) from
Church View Medical
Centre, linked to
Smoking Cessation
adviser presence and
Low Dose CT (LDCT)
provision locally
59
LHC delivered
for South Elmsall
and Hemsworth
cohorts
June 2019 to
November 2019
Chris Hunton working
with Conexus and CT
provider
WY & H CA budget committed via
contract with Conexus
1.3b Undertake the
practicalities of renting
and mobilising the
mobile CT scanner
CT scanner
contact in place
CT scans in the
community
Proposed new date:
July 2019 to
December 2019
Chris Hunton –
Wakefield Project
Manager, Lucy Beal &
Richard Robinson
(MYHT)
Linked in with NHS supply chain. Must
be purchased via acute Trust to
comply with framework
Work with Mid
Yorkshire Hospitals
Radiology to deliver
LDCT reporting of
images within 3 weeks
of acquisition
LDCT reporting
of images within
3 weeks of
acquisition
CT reports issued
in a timely
manner
July 2019 to
December 2019
Chris Hunton –
Wakefield Project
Manager, Lucy Beal &
Richard Robinson
(MYHT)
Funded from WY&H CA funding
60
Work with Mid
Yorkshire Hospitals
Respiratory to deliver
Triage MDT and patient
outcome back to
requesting GP
Work with Conexus to
deliver LHC outcome
reports to patients from
GP within 2 days of
report from MYHT
Radiology/Respiratory,
with support for
patients with positive
outcome
Appropriate
management of
patients with
positive LDCT
Appropriate
management of
patients in
secondary care
August 2019 to
January 2020
Chris Hunton/Georgina
Esterbrook
Funded from WY&H CA funding
Timely reporting
of LHC and LDCT
outcomes
Appropriate
management of
patients
June 2019 to
January 2020
Chris Hunton/Hazel
Taylor
Funded from WY&H CA funding
Engagement with LMC /
38 GP Surgeries
Informed GPs in
Wakefield
Appropriate
management of
patients
June 2019 to
January 2020
Dr Abdul Mustafa
(Clinical Lead Cancer
WCCG)
61
Mental Health
Priority Area 2: Mental Health
Health & Wellbeing Priorities:
Strengthening the role and impact of ill prevention & Ensuring a healthy standard of living for all
2.1: Provider
Collaboration
62
Action
Target
Outcome
Milestone
Owner
Resource
2.1.a – Co-produce
detailed work plan
for the
development of
the Alliance
Action plan
developed.
There is clarity
about roles,
responsibilities
and milestones.
End May
Sean Rayner
Alliance member
time.
2.1.b – Co-produce
the Mental Health
Outcome
Framework
Partners are
engaged in the
process.
There is clarity
amongst
partners about
collective
performance
against key
indicators.
End June
The indicators
give a holistic
overview of
system
performance.
Outputs from
the
Development
Session.
Alix Jeavons
Stakeholder
time.
2.1.c – Embed the
oversight and
assurance role of
the Mental Health
Alliance
Alliance
members have
a
comprehensive
understanding
of system
performance
and are
working
towards
addressing
challenges
collectively.
There is clarity
about roles and
responsibilities
and how they
align to the
overarching
Integrated Care
Partnership.
End September
Sean Rayner
Alliance member
time.
2.1.d - Identify
and establish
change agents
within each
Alliance
organisation
One Agent
identified for
each
organisation
The Change
Agents are able
to articulate the
benefits of an
Alliance and
work collectively
to identify and
reduce barriers
to change.
End December
Sean Rayner
Alliance member
time.
End September
Sean Rayner
Alliance member
time.
2.1.e - Identify and
deliver quick wins
to support joint
working
2.2: Delivery of
the Mental Health
work programme
63
2.2.a - Co-produce
detailed work
plans for each
mental health
priority area:
Action plans
with clear
milestones
developed.
I. Crisis
II. Chaotic
lifestyles
III. Suicide
Prevention
IV. C&YP
transformation
V. Dementia
2.2b – Identify
non-recurrent
investment
priorities
64
There is clarity
about what each
programme is
aiming to
achieve and how
it will go about
it.
There is clarity
about who has
been involved in
co-designing
each
programme.
Priorities and
outcomes
identified.
There is a clear
set of funding
priorities that
can support
achievement of
the MH
Investment
Standard.
Alix Jeavons
Partner time.
Sean Rayner
Alliance member
time.
i. End June
ii. End May
iii. End May
iv. End May
v. End April
End June
Elderly Care
Priority 3: Elderly Care
Health & Wellbeing Priorities: Strengthening the role and impact of illness prevention & ensuring a healthy standard of living for all
Action
Target
Outcome
Milestone
Owner
Resource
To work closely
with the Frailty
Prevention
Partnership, and
the Frailty
Prevention Group
(MYTH)
To decrease the
number of
conveyances to
the acute
setting, allowing
patients to stay
at home, and
receive care
closer to home
April 2019 – March
2020
Elderly Care Strategy
Group
Paula Bee, CEO Age Uk
Dr Ann Carroll SRO
Elderly Care and Frailty,
Nick Sutton,
programme manager
ICP
CCG, MYTH, FPP,
3.1 A
Frailty Prevention
Partnership will support
the Elderly Care and
Frailty workstream
across 19/20 by
prioritising the
following areas;
1. Loneliness and
isolation
2. Nutrition
3. Sensory
impairment
65
3.1.B
Reduce the number
transfers of care within
and between
organisations and
where possible
eliminating the need
for transfers of care
completely
3.1.C
Improvement of joint
and integrated working
between health, social
care and mental health
services
3.1.D
Improvement of timely
information sharing
between those involved
in a person’s care
including the sharing of
information with
people themselves and
importantly their carers
3.1 .E
Establish the utilisation
of Technology
Enhanced Care Services
(TECS) to support
people in their selfmanagement and to
support clinicians /
professionals in
securing health and
social care outcomes
66
Sign up from
partners
Reduced
number of
transfer of care
September 2020
Elderly Care Strategy
Group
Dr Ann Carroll SRO
Elderly Care and Frailty,
Nick Sutton,
programme manager
ICP
CCG
Sign up from
partners
Seamless
integrated care
September 2020
Elderly Care Strategy
Group
Dr Ann Carroll SRO
Elderly Care and Frailty,
Nick Sutton,
programme manager
ICP
CCG, Strategy Group,
LA
Sign up from
partners
Robust safe
transfer of
information
September 2020
Elderly Care Strategy
Group
Dr Ann Carroll SRO
Elderly Care and Frailty,
Nick Sutton,
programme manager
ICP
CCG, Strategy Group,
LA
Sign up from
partners
Seamless
integrated care
January 2021
Elderly Care Strategy
Group
Dr Ann Carroll SRO
Elderly Care and Frailty,
Nick Sutton,
programme manager
ICP
CCG, Strategy Group,
LA
3.1.F
Provide access to
intermediate
community-based
services as an
alternative to acute
hospital attendances
and acute hospital
admission
3.1.G
planned and “in time”
care co-ordination with
simplification of what
are often complex and
involved patient
management processes
Pathway designed Reduction in
and implemented attendance and
admission
January 2021
Elderly Care Strategy
Group
Dr Ann Carroll SRO
Elderly Care and Frailty,
Nick Sutton,
programme manager
ICP
CCG, Strategy Group,
LA
Sign up from
partners
Aligned services
January 2021
Elderly Care Strategy
Group
Dr Ann Carroll SRO
Elderly Care and Frailty,
Nick Sutton,
programme manager
ICP
CCG, Strategy Group,
LA
30% of care
homes have an
NHS mail account
Residential and
nursing homes
have access to
NHS mail
April 2020
Dr Ann Carroll SRO
Elderly Care and Frailty,
&
Nick Sutton,
programme manager
ICP
Access to NHSE
funding, working
with Richard Main
and team
3.1.H
NHS mail roll out to all
care homes
67
3.1.I
Review extension of
Telemedicine to more
homes
Six additional care
homes signed up
to telemedicine
including a
supported living
scheme
Reductions in
July 2019
conveyances
and
attendances.
Less pressure on
GP practices
Dr Ann Carroll SRO
Elderly Care and Frailty,
&
Nick Sutton,
programme manager
ICP
Working with
Immedicare
30% of care
homes have
access to patient
records
Residential and
nursing homes
have signed up
and using
End of April 2020
Dr Ann Carroll SRO
Elderly Care and Frailty,
&
Nick Sutton,
programme manager
ICP
Access to NHSE
funding, working
with Richard Main
and team
April 19 – March 20
Dr Ann Carroll SRO
Elderly Care and Frailty,
Nick Sutton,
programme manager
ICP
Primare Care Team
(WPPC3 Care home
element)
CCG, GP enhanced
service, care home
support team,
community
geriatricians and EOL
priority
April 18 – March 19
Dr Ann Carroll SRO
Elderly Care and Frailty,
Nick Sutton,
programme manager
ICP
Care Home Support
team linked with EoL
priority
3.1.J
Care Homes have
access to patient
records
3.1. K
Increase the number of
residents with advance
care plans (ACP) in care
homes
All residents care
homes to have an
advanced care
plan in place
3.1. L
Care Staff training and
education package
68
All staff have
access to a robust
training package
with an emphasis
on dementia and
EOL
All care homes
have access to
comprehensive
training
3.1.M
Development of a
Quality dashboard for
care homes
All care homes
have signed up to
the quality
dashboard
All partners
feed into and
have access to
the dashboard
April 19 – March 20
Local Authority
Dr Ann Carroll SRO
Elderly Care and Frailty,
Nick Sutton,
programme manager
ICP
Key input from
stakeholders across
Wakefield
All residential and
nursing homes
(65+) homes have
access to a robust
training package
for Dementia and
EOL
Qualified and
knowledgeable
staff across
Wakefield.
Improved
outcomes for
residents
April 19 – March 20
Working Group linked
with Mental Health and
EOL priorities
Care Home Support
Team, Community
Geriatricians linked
to the Workforce
strategy
Dr Ann Carroll SRO
Elderly Care and Frailty,
&
Nick Sutton,
programme manager
ICP
CCG, EC&F Partners
3.1.N
Develop robust training
package for Dementia
and End of Life in Care
Homes
3.1: O
Develop an Elderly Care
and Frailty Strategy
Group to oversee the
strategic development
and vision of the Elderly
Care and Frailty
workstream, ensuring
that the ongoing work
in frailty across the
district is co-ordinated
to maximise the
capacity of all services
across health social
care and 3rd sector
69
To align all
June 2019
resource that
interacts with
elderly care and
frailty, and
provide an
oversight
structure for the
SRP and
Programme
manager
organisations
3.1 P
Review the connecting
care hub offer and align
with Primary Care
Home – this will allow
Primary Care Home to
utilise and integrate
with the Connecting
Care Hubs effectively,
and work closely
together on specific
areas identified by
partners within the
Primary Care Homes
Work closely with
PCH and other
stakeholders to
review the CC
hub offer. Align
with the 7 PCHs
Less pressure on Sept 2019
GP practices
Dr Ann Carroll SRO
Elderly Care and Frailty,
&
Nick Sutton,
programme manager
ICP
Full evaluation of
CC and PIC
Identify and
work with key
partners to
produce the
evaluation
Dr Ann Carroll SRO
Elderly Care and Frailty,
&
Nick Sutton,
programme manager
ICP
3.1.Q
Produce a connecting
care evaluation,
including PIC audit &
interrogation to inform
future capacity and
demand of services
allowing partners to
evaluate performance,
and develop services
70
January 2020
across the Wakefield
place reflecting on
capacity and demand
across the system
3.1.R
Design and implement
a care home strategy,
which will cover;
Dementia in care
homes
Work with the
Primary care
Team to develop
the strategy
which will sit in
the WPPC3
Improve offer of
support to ALL
patients living in
a care home
July 2019
Dr Ann Carroll SRO
Elderly Care and Frailty,
Nick Sutton,
programme manager
ICP
Martin Smith, Head of
Commissioning for
Community,
CCG, Dementia
Board, Primary care
team
Attend Dementia
Board
To provide a
robust
dementia
strategy for the
Wakefield
system taking
into account
patients views
July 2019
Elderly Care Strategy
Group
Dr Ann Carroll SRO
Elderly Care and Frailty,
Nick Sutton,
programme manager
ICP
Alex Jeavons Senior
CCG, Dementia
Board
Relationship with the
Connecting Care hubs
Align with Primary Care
Home model to provide
an integrated approach
to the Enhanced Health
in Care Homes offer
held within the long
term Plan
3.1.S
Produce a dementia
strategy to support the
dementia offer across
the Wakefield place.
This will involve
multiple partner
consultations, and the
71
work will be led by the
Elderly Care and Frailty
Strategy Group

Commissioner for MH,
Dementia Board
Consider
aligning
dementia
under Elderly
Care and Frailty
workstream
3.1. T
Produce a
communications and IT
infrastructure for the
workstream that will
provide a development
plan, created by
partners to support the
integration of the
following:


72
SystmOne in
care homes
NHS Email for
care homes
Sign up from
relevant partners
Identified key
contacts within
partner
organisations to
enable
development
End of January 2020
Working Group – Nick
Sutton, programme
Manager
CCG, Strategy group
3.1 .U
Use data and evidence
locally to shape services
– the newly formed
Elderly care and Frailty
Strategy Group will
interrogate and analyse
relevant data to inform
the future shape and
development of
services across
Wakefield.
Work with LA and
Public health to
utilise data
providing regular
updates to ICP
Board
Key partners
who can
provide relevant
data.
April 19 – March 20
Dr Ann Carroll SRO
Elderly Care and Frailty,
Nick Sutton,
programme manager
ICP
Work with
partners to
interpret and
utilise the levers
held within the
long term plan to
shape services
across Wakefield
for the elderly
Provide more
robust services
for elderly
population
across
Wakefield
April 19 – March 20
Dr Ann Carroll SRO
Elderly Care and Frailty,
Nick Sutton,
programme manager
ICP
CCG, PCH, Wider
partners
Review data to
inform decision
making and
influence strategy
development
Provide more
robust
Strategies for
elderly
population
across
Wakefield
April 19 – March 20
Dr Ann Carroll SRO
Elderly Care and Frailty,
Nick Sutton,
programme manager
ICP
CCG, PCH, Wider
partners
3.1.V
Use the Long Term
Plans, and the new GP
contract as a lever to
enable development of
robust service
development and
change
3.1 .W
Access the newly
developed Integrated
Care System Population
Health Management
dashboard. The
dashboard brings
together national
datasets to enable
73
insight and
investigation into
national, system and
place populations and
the care they receive.
3.1.X
Improve
communications across
partnerships including
West Yorkshire
Ambulance service and
the Connecting Care
Hubs
3.2.a Look to improve
the patient/ user
experience using
patient and public
feedback to help shape
services
74
All partners will
be aware of offer
to our older
residents in
Wakefield
Patient
experience
feedback to
shape service
Seamless, coordination care
for our
Wakefield
residents
April 19 – March 20
Working with all priority Communications
work streams
teams
December 2019
Dr Ann Carroll SRO
Elderly Care and Frailty,
Nick Sutton,
programme manager
ICP
CCG, Healthwatch
Primary Care Home
Priority Area 4: Primary Care Home Action Plan 2019/20
Health & Wellbeing Priorities: Strengthening the role and impact of ill prevention & Ensuring a healthy standard of
living for all
Action
Target
Outcome
Milestone
Owner
Full list submitted
to PCH Steering
Group
To provide a
sustainable
governance
system to the
PCH model in
Wakefield
May 2019
Sean Rayner,
SRO for PCH
NAPC confirm
registration of all
7 PCHs
This will provide
PCHs with extra
resource (data &
analytics) and
further support
June 2019
Resource
4.1
PCH leadership
teams are
established
4.2
PCHs are registered
with NAPC
75
Nick Sutton,
Programme
Manager,
Wakefield ICP
Sean Rayner,
SRO for PCH
Nick Sutton,
Programme
Manager,
Wakefield ICP
PCH’s CCG,
Conexus, ICS,
wider partners
PCH’s, CCG,
Conexus
Action
Target
Outcome
Milestone
Owner
March 2020
Sean Rayner,
SRO for PCH
Resource
from NAPC
4.3
PCHs produce a local
set of outcomes
linked to chosen
priorities, and
develop baseline
data.
Outcomes and
baselines
submitted to PCH
Steering Group
This will allow a
structured and
informed
outcome
measure of the
progress of each
chosen priority
that will feed
into the
overarching PCH
assurance
framework
Network
agreements
revised to include
mechanism for
stakeholder
involvement
This will allow
systematic
evaluation of
stakeholders
involved within
each PCH and
provide
information to
CCG and ICP on
Nick Sutton,
Programme
Manager,
Wakefield ICP
PCH’s, CCG,
Public Health,
Conexus
4.4
PCHs produce a
mechanism for
stakeholder
involvement in
decision making
76
March 2020
Sean Rayner,
SRO for PCH
Nick Sutton,
Programme
Manager,
Wakefield ICP
PCH’s, CCG,
Conexus
Action
Target
Outcome
Milestone
Owner
Resource
stakeholder
engagement
March 2020
4.5
PCHs produce local
project plans
77
Project plans
presented to the
PCH Steering
Group
This will allow a
structured PMO
management of
the PCHs
allowing
potential risks
and issues to be
identified and
mitigated
appropriately.
Sept 2019
Sean Rayner,
SRO for PCH
Nick Sutton,
Programme
Manager,
Wakefield ICP
PCH’s, CCG,
Conexus
Action
Target
Outcome
Milestone
Owner
Resource
This will allow
the PCHs to
become formal
PCN’s within the
context of
NHSEs vision
held within the
Long term Plan,
and the new GP
contract
1st July
Sean Rayner,
SRO for PCH
PCH’s, CCG,
Conexus
4.6
All Primary Care
Sign-off complete
Homes sign the NHSE
PCN Direct Enhanced
Service
Nick Sutton,
Programme
Manager,
Wakefield ICP
Chris Skelton
Head of Primary
Care CoCommissioning
WCCG
4.7
Define model for
social prescribing
service
78
Model agreed by
PCH Steering
Group and
Network Chairs
Provide the
population of
Wakefield better
and faster
access to social
prescribing
Sean Rayner,
SRO for PCH
Nick Sutton,
Programme
Manager,
PCH’s, CCG,
Conexus, ICS
Action
Target
Outcome
Milestone
services
Owner
Resource
Wakefield ICP
Chris Skelton
May 2019
4.8
MoUs agreed
between provider
and PCH
79
MoUs signed off
Provide the
population of
Wakefield better
and faster
access to social
prescribing
Head of Primary
Care CoCommissioning
WCCG
Sean Rayner,
SRO for PCH
June 19
Nick Sutton,
Programme
Manager,
PCH’s, CCG,
Conexus, ICS
Action
Target
Outcome
Milestone
services
Owner
Resource
Wakefield ICP
Chris Skelton
Head of Primary
Care CoCommissioning
WCCG
4.9
All PCHs have a
named social
prescriber
PCH leadership
teams informed
of named social
prescriber
Provide the
population of
Wakefield better
and faster
access to social
prescribing
services
Sean Rayner,
SRO for PCH
July 19
Nick Sutton,
Programme
Manager,
Wakefield ICP
Chris Skelton
Head of Primary
Care CoCommissioning
WCCG
4.10
80
PCH’s, CCG,
Conexus, ICS
Action
Target
Outcome
Milestone
Owner
Resource
The Social
Prescribing
implemented fully
All staff
appointed
This will provide
a clear timeline
to the beginning
of service
delivery to
patients and
staff within
Wakefield
Sept 19
Sean Rayner,
SRO for PCH
PCH’s, CCG,
Conexus, ICS
Nick Sutton,
Programme
Manager,
Wakefield ICP
Chris Skelton
Head of Primary
Care CoCommissioning
WCCG
4.11
The Social
Prescribing
monitoring
framework is in place
81
To develop and
maintain a
monitoring
system of the
Social Prescribing
Service
This will provide
clear evidence
of usage and
outcomes of the
service
1st July
Sean Rayner,
SRO for PCH
Nick Sutton,
Programme
Manager,
Wakefield ICP
Action
Target
Outcome
Milestone
Owner
Chris Skelton
Head of Primary
Care CoCommissioning
WCCG
4.12
The Social
Prescribing service to
support PCH is
Evaluated
82
To fully evaluate
the service and
provide
recommendations
on the way
forwards
This will allow
commissioners
and other
partners to
model and
define the Social
Prescribing
service needed
moving forwards
that is tailored
to the
populations
needs
March 2020
Sean Rayner,
SRO for PCH
Nick Sutton,
Programme
Manager,
Wakefield ICP
Chris Skelton
Head of Primary
Care CoCommissioning
WCCG
Resource
Action
Target
Outcome
Milestone
Owner
New model
endorsed by the
PCH Steering
Group
Provide the
population of
Wakefield better
and faster
access to clinical
pharmacy
services
1st July
Sean Rayner,
SRO for PCH
Resource
4.13
DES Pharmacy in
General Practice
service defined
Nick Sutton,
Programme
Manager,
Wakefield ICP
Chris Skelton
Head of
Primary Care
CoCommissioning
WCCG
4.14
Clinical Pharmacy in
General Practice
implemented
83
Launch the
clinical pharmacy
service
This will provide
a clear timeline
to the beginning
of service
delivery to
patients and
staff within
August 2019
Sean Rayner,
SRO for PCH
Nick Sutton,
Programme
Manager,
PCH’s, CCG,
Conexus, ICS
Action
Target
Outcome
Milestone
Wakefield
Owner
Wakefield ICP
Chris Skelton
Head of Primary
Care CoCommissioning
WCCG
4.15
Clinical Pharmacy in
General Practice
monitored
Monitoring
system agreed by
PCH Steering
Group
This will provide
clear evidence
of usage and
outcomes of the
service
August 2019
Sean Rayner,
SRO for PCH
Nick Sutton,
Programme
Manager,
Wakefield ICP
Chris Skelton
Head of Primary
Care CoCommissioning
84
Resource
Action
Target
Outcome
Milestone
Owner
Resource
WCCG
4.16
Clinical Pharmacy in
General Practice
evaluated
Service evaluation
complete and
presented to
PCHG Steering
Group
This will allow
commissioners
and other
partners to
model and
define the Social
Prescribing
service needed
moving forwards
that is tailored
to the
populations
needs
March 2020
To provide a
Sept 2020
Sean Rayner,
SRO for PCH
PCH’s, CCG,
Conexus, ICS
Nick Sutton,
Programme
Manager,
Wakefield ICP
Chris Skelton
Head of Primary
Care CoCommissioning
WCCG
4.17
Develop a Primary
85
Workforce
Sean Rayner,
PCH’s, CCG,
Action
Target
Outcome
Care Workforce
analysis across PCH
footprint
analysis
presented to PCH
Steering Group
structures,
secure and
sustainable
Primary Care
workforce
Milestone
Owner
Resource
SRO for PCH
Conexus, ICP
(SRO for
Workforce)
Nick Sutton,
Programme
Manager,
Wakefield ICP
Develop a Primary
Care Workforce
strategy
Kerry Munday
Strategic Lead
for the Wakefield
General Practice
Resilience
Academy
4.18
Develop a Wakefield
Primary Care Home
leadership
development
programme model
86
Leadership
programme
agreed by PCH
Steering Group
To have a sound
PCH leadership
development
programme and
model that can
support the
workforce
across the PCH’s
July 2019
Sean Rayner,
SRO for PCH
Nick Sutton,
Programme
Manager,
Wakefield ICP
PCH’s, CCG,
Conexus,
Action
Target
Outcome
Milestone
Owner
Resource
Kerry Munday
Strategic Lead
for the Wakefield
General Practice
Resilience
Academy
4.19
Sign up from PCHs
to programme
PCH leadership
teams confirm
commitment to
engage with
programme
4.20
Programme starts
87
Programme
initiation event
takes place
This will provide
a more
substantial
leadership
programme
accessible to the
PCH workforce
Sept 19
Sean Rayner,
SRO for PCH
Nick Sutton,
Programme
Manager,
Wakefield ICP
PCH’s, CCG,
Conexus,
Action
Target
Outcome
Milestone
Owner
Resource
Kerry Munday
Strategic Lead
for the Wakefield
General Practice
Resilience
Academy
4.21
Explore potential for
WCCG Resilience
Academy to become
a vehicle of delivery
for the ICS
leadership
development
programme in
association with
NAPC
Model developed
for ICS-wide
leadership
programme
To have a sound
PCH leadership
development
programme and
model that the
ICS can adopt
and commission
Wakefield to
deliver across
the ICS region
March 2020
Sean Rayner,
SRO for PCH
Nick Sutton,
Programme
Manager,
Wakefield ICP
Kerry Munday
Strategic Lead
for the Wakefield
General Practice
Resilience
88
PCH’s, CCG,
Conexus,
Action
Target
Outcome
Milestone
Owner
Resource
Academy
4.22
Develop a PCH
communications
Strategy for the
Primary Care
workforce
89
Communications
strategy
presented to PCH
Steering Group
This will provide September
a greater
2019
opportunity to
share the
success of PCH
across Wakefield
and into the
wider NHS.
Sean Rayner,
SRO for PCH
Nick Sutton,
Programme
Manager,
Wakefield ICP
PCH’s, CCG,
Conexus
End of life
Priority Area 5: End of Life Care
Health & Wellbeing Priority: Strengthening the role and impact of ill prevention
Action
5.1a
5.1b
5.1c
5.2.a
90
Target
Finalise the future strategic
direction for End of Life Care
Future model
agreed.
Partners signed up.
Governance
arrangements
agreed.
Co-produce overarching work Partners are
programme for End of Life
engaged in the
Care that aligns with priority
process.
work streams including
The indicators give
Connecting Care, elderly care, a holistic overview
mental health, and workforce. of system
performance.
Implement the End of Life
The indicators give
Care Outcomes Framework
a holistic overview
of system
performance.
Population of
framework agreed.
Co-produce detailed work plan Action plans with
for the priority area:
clear milestones
integrated care (including
developed.
bereavement)
Outcome
Milestone
Owner
Resource
Partnership agreement
signed. Arrangements
implemented
August 2019
Hazel Pearce
and Michala
James
Input from key
stakeholders
Executive
leadership
support
Input from key
stakeholders
Clarity of work
programme, roles and
responsibilities
September
2019
Hazel Pearce,
Abdul Mustafa
& Michala
James
Outcomes framework
approved by ICP and
implemented by End of
Life Board
November
2019
Hazel Pearce
Input from key
stakeholders
There is clarity about:
-What each priority is
aiming to achieve and
how it will go about it.
- Who will deliver the
work plans
- Approval routes for
November
2019
Karen Benstead
(wider
integrated
model)
Michala James –
(integrated
bereavement)
Input from key
stakeholders
5.2.b
91
Co-produce detailed work plan Action plans with
for the priority area:
clear milestones
Training and Education
developed.
5.2c
Co-produce detailed work plan Action plans with
for the priority area: Service
clear milestones
improvements
developed.
5.2d
Link with frailty and dementia
work streams to co-produce
detailed work plan for
advanced care planning and
end of life care in Care Homes
Action plans with
clear milestones
developed.
change
There is clarity about:
-What each priority is
aiming to achieve and
how it will go about it.
- Who will deliver the
work plans
- Approval routes for
change
There is clarity about:
-What each priority is
aiming to achieve and
how it will go about it.
- Who will deliver the
work plans
- Approval routes for
change
There is clarity about:
-What each priority is
aiming to achieve and
how it will go about it.
- Who will deliver the
work plans
- Approval routes for
change
November
2019
Jo Schofield
November
2019
Michala James
November
2019
Tina Turner /
Input from key
stakeholders
Link with the
ICP Workforce
Transformatio
n Strategy
Group led by
Linda Harris
Input from key
stakeholders
Input from key
stakeholders
Enablers Action Plans Appendices
Appendix 1:
Workforce Delivery Plan
Appendix 2:
Communications and Engagement Plan
Appendix 3:
Housing Health and Social Care Partnership Plan
Appendix 4:
Estates Plan
Appendix 5:
Assurance Framework
92
Appendix 1: Workforce Delivery Plan
Priority One: - Workforce strategy and planning
Definition - To identify, analyse and predict the future workforce requirements for the Wakefield Connecting Care system
Health & Wellbeing Priority: Creating and developing sustainable places and communities
Deliverable
Outcome
Interdependency/ Lead
Timescale
Stakeholder
1.1
Redraft the Workforce Transformation
Strategy to focus on the ICP priority areas of
-
Mental health
-
EoLC
-
Elderly Frail
-
Lung Cancer
-
Primary care home
And to ensure compatibility with National
Workforce Strategy
93
System planning, and
workforce planning can
become integrated and
complimentary processes,
and become an enabler
for the Integration Care
programme (ICS) adopted
by Wakefield
The development of a
combined workforce
demographic at system
level will support system
redesign and integrated
recruitment and retention
adopting then 9 guiding
National
Workforce
strategy
WY and H LWAB
w/f strategy
Primary care
strategy
Dr L
Harris ,
SRO Lead
on behalf
pof the
HRDs
By end
quarter
two 19/20
RAG
Deliverable
Outcome
Interdependency/ Lead
Timescale
Stakeholder
principles of the workforce
strategy for connecting
care
1.2
All Wakefield ICS partners to formally adopt a
standardised workforce Data Sharing
Agreement, with acknowledgement that
moving towards shared collation
methodology would aid population health
planning
A planning process that is
system wide and includes
effective communication
between HR (and CEO/Ops
Director leads in smaller
organisations) and
commissioners
NMDS-SC data is utilised fully in Wakefield
population health modelling, and further
National
Workforce
strategy
By end
quarter 4
19/20
WY and H LWAB
w/f strategy
Primary care
strategy
provision is made to include full social care
workforce data from the independent sector
All Wakefield ICS partners agree to workforce
data use for planning and modelling
purposes, and becomes the responsibility of
the Wakefield Connecting Care HRD Hub
group
1.3
94
Wakefield adopts a whole population
A flexible approach to
National
By end
RAG
Deliverable
Outcome
Interdependency/ Lead
Timescale
Stakeholder
approach to workforce data modelling
andcommissions ‘Whole Systems partnership’
to develop a workforce modelling tool (or
alternative supplier)
workforce planning which
does not seek long term
predicative precision but
can identify and respond
to potential medium-term
issues enabling the
workforce to evolve and
adapt to inherently
unpredictable health and
care environment
Workforce planning that
ensures system change
priorities are met and skill
mix is reflective of service
user need
95
Workforce
strategy
WY and H LWAB
w/f strategy
ICP business plan
quarter
one 18/19
RAG
Priority two – Enhancing and Growing Systems Leadership
Definition - Wakefield will have a robust, agile and flexible cohort of leaders in Wakefield who will collectively develop and enable the transformation
journey of bringing together best elements of health, housing, social care and the VSCE
Health & Wellbeing Priority: Creating and developing sustainable places and communities
2.1
Deliverable
Outcome
Interdependency Lead
Timescale
ICP approves the mandating and resourcing of
a Connecting Care HRD Workforce
Transformation Hub – whose role will be to
embed the Workforce Transformation
Strategy
Wakefield ICs system leads
have one common set of
principles and standards –
and this becomes the
blueprint for managing the
layers of transformational
change.
National
workforce
strategy
By end
quarter
two 18/19
The hub will in part be
virtual and hosted by a
system partner
organisation. Hub resources
across the whole system to
comprise HR and OD
resources from across the
‘place’ based system and
aligned to an agreed
structure with supporting
administration
96
STP/LWAB
Wakefield Place
– Health and
Wellbeing
RAG
rating
2.2
Deliverable
Outcome
Interdependency Lead
Timescale
ICP will provide OD, leadership and systems
development support across the system ,
respecting the unique identities of partner
organisations
Wakefield has a responsive
and forward-thinking
cohort of leaders which
ensures an aligned
approach to
transformational incentives
National
workforce
strategy
By the end
of quarter
four 18/19
A common ‘culture barometer’ will be
adopted to ensure we benchmark the culture
of care aligned to the compassionate care
project being led by Healthwatch Wakefield
Leaders model the way by
adopting the nine guiding
principles and aligning their
own respective workforce
challenges to the strategic
workforce objectives of
Connecting care
STP /LWAB
Wakefield Place
– Health and
Wellbeing
Leaders agree to adopt the
NHS Culture care barometer
2.3
97
Commonly adopted workforce KPIs and
business change methodologies are adopted
across the system leads and governance
structures reflect this formal adoption,
Wakefield continues to
National
work collaboratively to
workforce
develop the systemic mind- strategy
set, based on a common
purpose of achieving person
By the end
of quarter
four 19/20
1
RAG
rating
Deliverable
Outcome
Interdependency Lead
centred seamless care
STP /LWAB
Timescale
RAG
rating
Wakefield Place
– Health and
Wellbeing
Priority three – growing talent and securing resilience
Definition - Attracting, recruiting, retaining and developing a resilient health, care and support workforce to deliver the Connecting Care vision
Health & Wellbeing Priority: Creating and developing sustainable places and communities
3.1
Deliverable
Outcome
Create an action plan to implement system
sign up and active engagement with the
Wakefield Workplace Wellbeing Charter
Established, trusted and
successful workplace
wellbeing resources in place
to support the whole staff
cohort
Workplace wellbeing charter mark or
similar benchmark to be held by all
organisations in Connecting Care
98
Interdependency Lead
Timescale
By end of
year 2 19/
20
RAG
rating
3.2
Deliverable
Outcome
Develop a Wakefield Wellbeing and
Resilience Strategy for staff and volunteers;
by evaluating and utilising the results from
the Wakefield Workplace Wellness
programme. This strategy will be
developed with the specific input of the
Mental health strategy group and will
focus on how to empower staff to identify
their own mental health needs
A Wakefield wide approach
to staff wellbeing that fully
considers the parity of
mental health and provides
suitable support and
resources for staff
Workplace wellbeing
champions network in place
and active across the
system including carer
specific wellbeing
interventions and a cohort
of mental health first aiders
System commits to adding
value to the existing
occupational health
resources in place by
committing to
implementing an evidence
based comprehensive staff
wellness healthcheck for all
99
Interdependency Lead
Timescale
By end of
year 2 19/
20
RAG
rating
Deliverable
Outcome
Interdependency Lead
Timescale
staff in Connecting Care
Reduced staff sickness rates
and improved presentism
across the operating system
3.3
3.4
100
Develop Connecting Care recruitment
strategy and implementation plan, with
emphasis on value-based recruitment
practices and skill mix. The strategy will be
inclusive of the third sector whose skills
will be recognised as contributing to
business change alongside citxen
empowerment through recruitment to
peer led initiatives and will support the
attainment of the ICP priority area
objectives (see above)
Wakefield ICS will enable
people with the right values
and behaviours to working
in the Wakefield.
Establish a virtual ICS health and social
care academy , including induction, joint
learning platform, training and
development products scaled up and rolled
Wakefield ICS will enable
people with the right
values, skills, competencies
and behaviours to deliver
By end of
quarter
four 18/19
Proactively and collectively
manage on
vacancy/turnover rates
Proactively and collectively
manage career progression
opportunities
By end of
year 2
19/20
RAG
rating
Deliverable
Outcome
out to ICS
the ICS in Wakefield.
Interdependency Lead
Timescale
RAG
rating
Formal relationships with
Universities, Education and
learning providers, which
offer new routes for roles
such as advanced
practioner’s and physicians
associates
Priority Four – Redesign -new roles, new ways of working
Definition - Innovating and adapting our health and social care workforce in Wakefield by creating, piloting and embedding new ways of working and new
roles into the infrastructure of our delivery models.
Health & Wellbeing Priority: Creating and developing sustainable places and communities
4.1
Deliverable
Outcome
Scale up and plan for (population health
based) roll out of new roles in -
A professional competent
workforce able to work in a
person-centred manner.
New roles supporting new
models of care in Wakefield
which focus on prevention,
partnership,
- physio first
- care navigation
101
Interdependency Lead
Timescale
By end of
year 2 19/
20
RAG
rating
Deliverable
Outcome
- pharmacy first
personalisation, evidence
and innovation
- frailty approaches
Interdependency Lead
Timescale
- trusted assessor
- extended GP services (nurse led)
- telemedicine (Airedale Model)
- one gp, one care home
- mental health navigators
- Improved IAPT
- primary care mental health workers
4.2
102
Develop learning and development
frameworks for new ways of working
which are aligned to national and local
competency frameworks – e.g. Connecting
Care EOL framework
As above
By end of
year 2 19/
20
RAG
rating
Priority Five – Staff engagement – culture change
Definition - Actively engages the workforce to support the cultural change programme required to support transformation for integration in Wakefield and
the capacity and competence of the workforce to be strengthened.
Health & Wellbeing Priority: Creating and developing sustainable places and communities
5.1
Deliverable
Outcome
Develop an ICS Staff engagement strategy
and implementation plan , in partnership
with all relevant Connecting Care plus
enablers
Wakefield will have a
system wide understanding
of transformation and
integration, and will have
culture of readiness for
change from front line staff
to system leaders
Interdependency Lead
Timescale
By end
quarter 3
18/19
HRDs have aligned their
respective staff
engagement strategies and
shared relevant findings of
respective staff surveys
5.3
103
Create a network of Connecting Care
change champions/ambassadors, who
joint staff engagement
strategies for Connecting
Care draw on findings from
regulatory action plans
Staff from all grades, levels
and posts have access to
By end of
quarter 4
RAG
rating
Deliverable
Outcome
support and inform staff of benefits of
Connecting Care approach and ongoing
developments
informative and accessible
information on
transformational change
These staff will model the
way in terms of the
workforce transformation
strategy. Key messages
around seamless patient
centred care and
development of the third
sector
104
Interdependency Lead
Timescale
18/19
RAG
rating
Appendix 2: Communications and Engagement Plan
Health & Wellbeing Priority: Creating and developing sustainable places and communities
Communications, engagement and equality are a key enabler in the delivery of the Connecting Care+ Business Plan which is overseen by the Integrated
Care Partnership Board, and overall led by the Health and Wellbeing Board. The Communications, Engagement and Equality Plan needs to reflect:
•
•
•
•
A district-wide communications, engagement and equality partnership that maximise best use of resources and skills
Patient and public voice on relevant service changes with feedback gathered to support the programme of work
The delivery of any communication in-line within the workstreams of the Business Plan
Ensuring that the Business Plan maximises opportunities to promote equality, that engagement reaches diverse communities and communication is
accessible.
The Plan will support the workstreams and other enabling support elements of the overall ICP Business Plan, and work alongside these to ensure clarity on
which elements of the five priority areas and enablers require support. The Plan will be delivered by our district-wide Communications and Engagement
Working Group, with support as required from our Community Engagement Partnership and Equality and Cohesion Group, in line with our agreed
engagement and communication objectives and principles, as below:
•
•
•
•
•
•
•
•
•
105
Be open, honest, consistent, clear and accountable
Ensure communications and engagement activities are accessible to all audiences
Give clear, accurate and consistent messages, linked to the overall Connecting Care+ programme’s visions and values
Ensure planned, timely, targeted and proportionate communication and engagement
Provide cost-effective, high quality information – maximising our resources
Work in true partnership with other agencies, stakeholders, patients/service users, carers and patient representatives to reduce health inequalities
and improve health outcomes
Lead by example and learn by what we do – both by what we do well and what we can improve
Provide a variety of innovative, creative opportunities to communicate with people and for people to engage with us
Use best practice methods and encourage our member practices to adopt these principles.
Note: The above objectives and principles were taken from our 2017 MCP Communications and Engagement Plan. We have now developed our own CCG
principles, which were pulled together following engagement from local patients. Use these instead?
The Communications, Engagement and Equality Plan will be refreshed on an annual basis by the group to ensure we are working flexibly in-line with the
Connecting Care+ programme as it develops. Progress against the Plan will be tracked through both the workstreams outcomes and fed back to the ICP
Board.
Communications, Engagement and Equality Plan 2018- 2021
Governance:
Communications, engagement and equality will be led from the Health and Wellbeing Board (HWB), and overseen by the ICP Board. This structure will
ensure we are provided with direction and buy in from all partner organisations.
Outcomes from the HWB are cascaded through representation at the Board, to communication, engagement and equality leads in partner organisations. In
addition, a representative from the Board is further linked into our group, to ensure we have direct contact with the HWB Plan.
Our communications, engagement and equality groups work across the following Boards and groups to deliver the Connecting Care+ vision:
106
Community
Engagement
Partnership
Communications
and Engagement
Working Group
Equality and
Cohesion Group
Key Outcomes:
The work plan below will be owned by the Connecting Care+ communications and engagement group which will deliver the agreed Plan in line with the
Terms of Reference (ToR) for the group:
 A joint Communications and Engagement plan, owned and delivered by all member partners, identifying the key campaigns and communications activity
to be undertaken and directing resources where they have maximum impact
 Raising awareness of campaign messages and the visibility of campaigns, utilising partners and stakeholders communications channels and networks
 Simplify key messages so they are meaningful to target audiences
 Facilitating and supporting behaviour change and enabling cultural shift
107
 Encouraging public involvement in shaping health and social care services
 Establishing working groups to facilitate, support and deliver identified projects and campaigns to promote key health and wellbeing messages for the
Wakefield District.
 Establishing four development sessions a year for the group
 Follow media protocols agreed across the group.
Delivery Plan:
Topic/Action
Target
Outcome
Resources
Interdependencies
Lead
Timescale
Connecting Care+
staff
Other health, social
and VCSE colleagues
Service users
Public
Media
PIPEC
•
Up to date and timely
information being fed
down from ICP Board
News articles being
contributed for
promotion across
partners
CCG
•
Ongoing
•
Ongoing
Connecting Care+
staff
Other health, social
and VCSE colleagues
Service users
Public
Media
Connecting Care+
staff
Other health, social
and VCSE colleagues
Service users
•
Up to date and timely
information being fed
down from ICP Board
Key campaign
messages agreed by
our group and shared
All
•
Ongoing
Educating staff on the
changes of the
branding
All
•
Ongoing
ASSETS
Connecting Care+
website
•
•
Social Media
108
Transfer and rebuild on CCG site
•
•
•
Add in tools to
ensure better
accessibility
•
Manage and
update all
accounts
Keep growing
follower accounts
•
Ensure roll-out of
Connecting
Care+ branding
•
•
Connecting Care+
branding
Manage and
update website
•
•
Ensure all
programme
information is
kept up to date
on the site
Update news
section
Test with
patients
representatives
Ensure
messages are
consistent and
accessible
across each
social media
platform
Act as brand
guardians to
ensure
Connecting
Care+ is used by
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Connecting Care+
videos
•
Connecting Care+
newsletter
•
Printed Materials
•
•
Connecting Care+
email inbox
•
Create a suite of
accessible videos
on the
Connecting
Care+
programme
•
Develop monthly
newsletter
•
•
•
Utilise current
suite of printed
materials
including;
brochures, handouts etc.
Keep producing
up to date and
accessible
materials
•
Manage inbox
•
•
•
•
all partners
Share templates
and high
resolution logos
internally
Produce and
create films
Promote and
utilise films
Ensure
accessibility
requirements
Work on rota
basis to pull
together monthly
newsletter
Materials to be
shared within our
group
Production of
Connecting
Care+ materials
shared for signoff
Easy read
versions of the
materials to
ensure
accessibility to all
Check numerous
times daily
Respond in
timely manner
•
•
Public
Media
•
Connecting Care+
staff
Other health, social
and VCSE colleagues
Service users
Public
Media
Connecting Care+
staff
Other health, social
and VCSE colleagues
Connecting Care+
staff
Other health, social
and VCSE colleagues
Service users
Public
Media
•
Difficulties in getting
staff booked in for
interviews
CCG
•
Ongoing
•
Need all partners to
input articles for the
newsletter
All- rota
basis
•
Ongoing
•
Requests for
materials producing to
be received in good
time to allow sign-off
processes required
All
•
Ongoing
Connecting Care+
staff
Other health, social
and VCSE colleagues
Service users
Public
Media
•
Support required from
operational
colleagues to help
with responses to
those emails received
in the inbox
CCG
•
Ongoing
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
109
District-wide group
•
•
•
PIPEC
•
PRG Network
Equality Health
Panel
•
Establishing four
development
sessions a year
for the group
Develop working
groups for
relevant
campaigns that
sit under the five
priorities
Support
colleagues in
Connecting
Care+ work
Ensure we meet
our statutory duty
to engage.
•
Intelligence
sharing and
gathering
•
Deliver the Plan
•
Deliver
assurance
groups with
members of the
public and
representatives
of local third
sector
organisations
Gather and
share
intelligence
Need sign-off from all
partner colleagues on
the Plan
All
•
Ongoing
•
•
•
•
•
•
VCSE colleagues
Service users
Public
CCG
•
Ongoing
•
•
•
VCSE colleagues
Service users
Public
CCG
•
Ongoing
•
•
•
Connecting Care+
staff
Other health, social
and VCSE colleagues
Service users
Public
Media
Summary
Our Communications, Engagement and Equality Plan is a flexible, working document. The Plan will consistently be agreed by our Communications and
Engagement Working Group and will be fed-back to the ICP Board.
110
111
Appendix 3: Housing Health and Social Care Partnership Plan
Action Plan update 2019/2020
Action
Target
Outcome
Responsible
Resources
Target /
Completion
date
Progress
1. Strategic Objective: Strengthening the role and impact of ill health prevention.
Health and Wellbeing Priority: A shift towards allocation of resources based upon primary and secondary prevention and
social determinants of health.
HHSCP Key Outcome: Reduced pressure on 999 calls and A&E attendance.
1.1
WDH
Roll out Care Link
60% of
Reducing 999 calls
reablement service to Reablement
and A&E
Wakefield
Bullenshaw hub.
patients take up
attendance.
Council
offer of telecare
technology as a
Preventing hospital
long term support
admission and
option.
readmission.
Care Link
April
2018
1.2
Develop Responder
service as part of the
Reablement offer.
Respond to
Reablement fallers
within
30 minutes of
receiving an alert.
Reducing 999 calls
and A&E
attendance.
WDH
Wakefield
Council
CCG
Responder
resources
April
2018
1.3
Train Practice Nurses
and Community
Nurse teams on Care
Link technology and
service.
100% Nursing
teams receive
training.
Reducing 999 calls
and A&E
attendance.
WDH
MYHT
Care Link team
December
2018
112
Action
Target
Outcome
Responsible
Resources
Target /
Completion
date
1.4
Establish partnership
between YAS and
WDH to reduce
number of ambulance
calls in relation to
fallers.
Agree SLA
between both
organisations for
the provision of
Responder as part
of 999 triage.
Reducing 999 calls
and A&E attendance
WDH
YAS
Resources
identified as
part of SLA
December
2018
1.5
Identify existing Care
Link customers who
are repeat fallers and
target for Responder
Service.
70% Repeat fallers
move onto
Responder
Service.
Reducing 999 calls
and A&E attendance
WDH
Care Link data
April
2018
Progress
Preventing hospital
admission and
readmission
2. Strategic Objective: Ensuring a Healthy Standard of Living for All.
Health and Wellbeing Board Priority: Radical reduction in hospital admission where appropriate leading to reinvestment in
prevention.
HHSCP Key Outcome: Reduce housing related delayed discharge through the provision of warm and healthy homes.
2.1
Implement HSC at
Fieldhead Hospital.
Reduce DTOC
cases linked to
housing by 50%.
Reduce housing
related DTOC.
Mental Health
patients sustaining
accommodation in
the community.
113
WDH
SWYPFT
SWPFT
contract
April
2018
Action
Target
Outcome
Responsible
Resources
Target /
Completion
date
2.2
Reduce DTOC
cases linked to
housing by 50%.
Reduce housing
related DTOC.
WDH
Wakefield
Council
MYHT
WCCG
WCCG
contract
June
2018
WDH
SWYPFT
WDH
March
2019
Implement HSC at
Pinderfields Hospital.
Reduce
readmissions to
hospital.
2.3
Evaluate the role of
the HSC
Evaluate the SROI
for the first 12
months.
Reduce housing
related DTOC.
Reduce
readmissions to
hospital.
2.4
Community facilities
and guest flat
accommodation to
support hospital
pressures and earlier
discharge.
Four schemes
established as
support to Delayed
Transfer of Care
patients.
Reduce housing
related DTOC
WDH MYHT
Independent
Living Team
March
2019
2.5
Evaluate outcomes of
Community Anchors
project at Hatfield
Court and
Springfields.
Make links with the
wider community to
provide social
activities for
Independent Living
tenants.
Reduction in social
isolation as wider
determinant of
health.
WDH
CCG
NICHE
Health Watch
December
2018
114
Progress
Action
Target
Outcome
Responsible
Resources
2.6
Develop Stoneygarth
new build
Independent Living
scheme including
provision for
reablement and
rehabilitation services.
One new build
scheme developed
in Wakefield.
Reducing hospital
bed days.
WDH
Wakefield
Council
HCA Capital
funding
February
2021
2.7
Develop and launch
“Healthy Housing
Hub” referral pathway.
Launch scheme
and receive
referrals.
Providing warm
healthy homes.
Wakefield
Council
Wakefield
Council
NHS teams
September
2018
2.8
Secure funding for
continuation of Fuel
Poverty Fund heating
scheme.
Secure funding
and launch
scheme.
Providing warm
healthy homes.
Wakefield
Council
Wakefield
Council
Ongoing
2.9
Deliver Warm Homes
Fund heating
improvement scheme.
Assist 30
households.
Providing warm
healthy homes.
Wakefield
Council
Warm Homes
Funding
March
2018
2.10
Deliver a training
programme on
housing condition and
fuel poverty
awareness for public
health and social care
teams.
Deliver training to
key teams in the
district.
Providing warm
healthy homes.
Wakefield
Council
Wakefield
Council
Ongoing
2.11
Complete delivery of
2017/2018 Fuel
Poverty Plan.
Assist 25
households.
Providing warm
healthy homes.
Wakefield
Council
LGF funding
September
2018
115
Target /
Completion
date
Reducing housing
related DTOC.
Progress
Action
Target
Outcome
Responsible
Resources
Target /
Completion
date
2.12
Complete delivery of
Castleford External
Wall Insulation
Scheme.
Assist 76
households.
Providing warm
healthy homes.
Wakefield
Council
LGF Funding
December
2018
2.13
Develop and launch
Poverty Package pilot
scheme providing a
multifaceted approach
to tackling fuel
poverty.
Assist 250
households.
Providing warm
healthy homes.
Wakefield
Council
Wakefield
Council
September
2019
3.
Strategic Objective: Creating and Developing Sustainable Places and Communities.
Health and Wellbeing Board Priority: New integrated care systems to deliver new models of care.
HHSCP Key Outcome: Housing related support integrated into new models of care.
3.1
Explore opportunities
and the need for
mental health
homeless support.
Reduction in
mental health
homeless cases.
Mental health
support to sustain
healthy home
SWYPFT
Funding
sources to be
explored
January
2018
3.2
Raise awareness
about the new
Housing Related
Supported pathways
model and the Single
point of access for
homeless.
All key partners
trained on referrals
route.
Housing related
support to sustain a
healthy home
Wakefield
Council
Wakefield
Council and
Commissioned
providers
December
2018
116
Progress
Action
Target
Outcome
Responsible
Resources
Target /
Completion
date
3.3
Expand Cash Wise
support for private
sector tenants and
homeowners.
20% of Cash Wise
referrals and
supported
provided to non
WDH.
Tackling poverty as
a wider determinant
of health.
WDH
WDH
CCG
August
2018
3.4
Explore options for
developing Healthier,
Wealthier Children
pilot in Wakefield
district using Cash
Wise support.
Develop referral
pathway for pre
and ante natal
health
professionals to
refer clients to
Cash Wise.
Tackling poverty as
a wider determinant
of health.
WDH
CCG
Cash Wise
March
2019
3.5
Identify third sector
resources that are
supporting individuals
with homelessness
and ensure their
services are
maximised with
statutory partners.
Consult with NOVA
members on
services currently
offered.
Homeless
prevention.
NOVA
NOVA
May
2018
117
Progress
Action
Target
3.6
Explore the
opportunities for
Community Led
Housing within the
District, disseminating
to the sector learning
from successful
schemes elsewhere
and identifying
opportunities to
develop one or more
projects locally.
3.7
3.8
118
Outcome
Responsible
Resources
Target /
Completion
date
Up to three
Securing health
workshops are held homes for homeless
within the VCSE
people in the district.
sector.
Nova
Nova Learning
and
Development
Network
National CLT
Network
North East
Yorks and
Humber Self
Help Housing
Group
Locality
31.3.19
Contribute to
consultation on Local
Development
Framework (LDF).
The health and
care sector are
involved in every
element of the
consultation
process for the
LDF review.
Health services and
new Housing
developments are
integrated.
CCG
Estates,
housing and
strategy leads
across the
health and
social care
sector
2020
Influence LDF on
Healthy New Town
principles
The refreshed LDF
reflects the key
concepts of the
Healthy New
Towns
programme.
Health services and
new Housing
developments are
integrated.
CCG
WDH
Estates,
housing, public
health and
strategy leads
across the
health and care
sector
March
2019
Progress
Action
Target
Outcome
Responsible
Resources
Target /
Completion
date
3.9
An estate strategy
for the health and
care system
developed in a
collaborative way,
enabling the
delivery of health
and care.
Health services and
new Housing
developments are
integrated.
CCG
Estates,
housing and
strategy leads
across the
health and care
sector
December
2018
Develop a
comprehensive
Estates Strategy for
the Wakefield Health
and Care sector
linking to the West
Yorkshire and
Harrogate Health and
Care Partnership
Estates and Capital
Strategy.
Progress
4. Strategic Objective: Giving Every Child the Best Start in Life.
Health and Wellbeing Board Priority: A strong ambitious co-owned strategy for ensuring safe healthy futures for children.
HHSCP Key Outcome: Improved aspirations for young people living in our neighbourhoods.
4.1
119
Explore options for
partner participation
and contribution to the
Community
Leadership
programme with the
Outward Bound Trust
targeting specific
groups such as young
carers.
5 Young Carers
participating on
each Community
Leadership
Programme.
Reduce childhood
obesity.
Improved metal
resilience for young
people in Wakefield.
WDH
Public Health
Public Health
Carers
Allowance
December
2018
Action
Target
Outcome
Responsible
Resources
Target /
Completion
date
4.2
Deliver Life
Choices
programme in 12
Primary /
Secondary
schools.
Provide children
with skills around
financial capability
and advice on
careers,
employability and
wellbeing.
WDH
Cash Wise
March
2019
5.
Increase capacity for
Cash Wise to deliver
Life Choices
programme in
schools.
Operational Objective: Ensure housing, health and social care legislation and policy is considered and appropriately
disseminated.
5.1
Implement Homes
for Health check list
to ensure key
strategies and plans
recognise the homes
contribution to health.
100% of relevant
plans agreed by
CCHSCP to
consider the
contribution of
housing to health.
Key strategies and
plans in the
Wakefield District
recognise the
contribution of
housing to overall
health and
wellbeing.
CCHSCP
CCHSCP
March
2020
5.2
Contribute to the
consultation on the
Social Care Green
Paper reflecting
housing as a wider
determinant of
health.
Respond to
Governments
consultation.
Social Care Green
Papers recognises
the contribution of
housing to Health
and Social Care.
HHSCP
HHSCP
December
2018
5.3
Raise awareness of
the extended
Homelessness duty
from revised
legislation.
Carry out training
with key teams
across the district.
All partners are
aware of the
Homeless duty.
Wakefield
Council
WMDC
December
2018
120
Progress
Action
5.4
Prepare for and
implement “Sheltered
Housing Rent” in
response to
Governments
consultation on the
Future Funding of
Supported Housing.
Target
Outcome
Responsible
Resources
Target /
Completion
date
Implement
sheltered rent for
all WDH sheltered
tenants.
Older people are
supported to live
independently in
their own home.
WDH
WDH
March
2020
Progress
Technology Model – Project plan
Note: This plan will develop to reflect the technology needs of the wider connecting care projects
Deliverable
1
1.2
Infrastructure & enablers
Implement Health and Social care
network
1.3
Maximise opportunities for agile
working supported by NHS WIFI
infrastructure
1.3
Implement NHSMail and Skype for
Business
121
Target
Outcome
Interdependency/
Stakeholder
Lead
Timescale
First practices to
migrate by Q3
2018.
Improved network
infrastructure across
NHS & Local
Authorities
More responsive
services at point of care
NHS Digital
Yorkshire and
Humber Public
sector network
NHS Digital
Connecting Care
partners
R Main
May 2018
to March
2020
R Main
Jan 2018 to
March
2020
NHS Digital
CKW ICT shared
service
R Main / I
Wightman
April 2019
to March
2020
WiFi implemented
in 95% of
practices by Jan
2018.
Develop migration Improved secure email
plan for practices and messaging
and CCG by Q3
2018. Migration
from Q1 2019
RAG
1.4
2
2.1
Deliverable
Target
Outcome
Implement collaborative working
environment for all partners to enable
secure and auditable sharing of both
management and personal identifiable
data
Service delivery
Complete implementation of PIC to
Wakefield GPs
Develop with
WY&H partners as
part of LHCRE
(subject to NHSD
exemplar bid)
Improve ability to
manage across existing
organisational
boundaries
Review of service
demand end June
2018. Continued
rollout to be
agreed post July
2018
Review post July
2018 (as 2.1
above)
Two pilot
practices to
implement
procured system
in Q2 2018
Carry out Due
Diligence with
LTHT for proposed
use of PPM+
Develop with Y&H
partners as part of
LHCRE (subject to
NHSD exemplar
bid)
Develop as part of
case for use of
2.2
Extend use of PIC to other referral
pathways and services
2.3
Implement GP online consultation
Extend model to support care
navigation approach
2.4
Implement electronic patient record in
acute and community trust
2.5
Develop local or regional shared health
and care record
2.6
Extend sharing of EoL and LTC care
preferences to all partners and
122
Interdependency/
Stakeholder
NHS Digital
WY&H ICS Digital
Team
Connecting Care +
partners
Lead
Timescale
R Main
April 2019
to March
2020
Improve information
flow for care of frail and
elderly
Connecting Care +
partners
R Hurren /
D Newton
October
2018
Improved
communication and
care of frail and elderly
Support GPFV and
further develop care
navigation
Connecting Care +
partners
R Hurren /
D Newton
April 2019
NHS England
WY&H ICS Digital
Team
CKW ICT shared
service
MYHT
R Main / I
Wightman
May 2018
to April
2020
H Cook
TBC
Improve visibility of
patient data across
health and care services
Regional / STP /
WYAAT / CC+
STP TBC
TBC
Better meet patient
wishes
WY&H ICS Digital
Team
TBC
TBC
Improve visibility of
patient data across
health services
RAG
2.7
2.8
Deliverable
Target
integrated urgent care
LHCRE (also see
2.7 below)
Project group led
by Hospices
working across
system partners
Refresh and extend use of the
Electronic Palliative Care Co-ordination
System (EPaCCS) template to better
support information sharing at End of
Life
Support the implementation of remote
consultation (telecare / telemedicine)
2.9
Develop a person held care record
2.10
Develop alerts and messaging between
services
2.11
Universal capabilities - continue to
develop and promote uptake of
123
Airedale
Telehealth model
implemented in 3
care homes in Q2
plus 5 in Q3. Also
option for WDH
supported living
in Q2.
LHCRE Proposal
includes
development of
the Leeds person
held record
(HELM) on a
regional footprint
Dependency on
MY due diligence
for an EPR (see
2.4)
STP Digital
engagement team
Outcome
Interdependency/
Stakeholder
/ STP / WYAAT /
CC+
Connecting Care +
partners
Lead
Timescale
Hospice
May 2018
to April
2020
Improve access to
services across all
sectors
Initial work in Care
Homes.
Care Homes/
Airedale FT / STP
L Carver
2018/19
Improve ability to selfcare and record and
share personal data
WY&H ICS Digital
Team;
STP / regional
STP
TBC
GPs can understand
who is in hospital at any
time.
Community teams will
be alerted when a frail
person attends A&E or
is admitted
Increase digital maturity
of partners and improve
Connecting Care +
partners
TBC
TBC
NHS E
NHS D
R Main
April 2018
– March
Improve information
flow for care patients at
or approaching EoL
RAG
3
3.1
3.2
124
Deliverable
Target
Outcome
National programmes including :
• Electronic Referrals, Advice
and Guidance
• Electronic Prescribing
• Discharge to Social Care
• Child Protection Information
System
• Patient online access to
primary care
• E-Discharge letters
• Enriched summary care record
will promote as
part of online
consultation (see
2.3) during Q3
&Q4 2018
service delivery
Business Intelligence
Develop business intelligence model
utilising a pseudonymised and linked
datasets
Ensuring re-identification only possible
for direct care to enable risk
stratification “case finding”
Publish key MI to connecting care hub
partners on a dynamic basis
Interdependency/
Stakeholder
Primary and
secondary care
partners
STP
CKW shared ICT
service
Lead
Timescale
Public Health
S Mullen
April 2018
– March
2019
Connecting Care +
partners
A
Hemingway
April 2018
to
December
2018
2020
Note:
Locally we will be
implementing
OSCAR to
supplement NHSD
Electronic
Referrals, Advice
and Guidance
Awaiting approval
of model by NHSD
DARS service.
MI in respect of
multi-agency
referrals is
collated on a
monthly basis.
Wider reporting
of all partners is
Support delivery of
population heath
management and
associated
commissioning of
services.
Support targeted
interventions
Better awareness of
demands and capacity
of local system
RAG
Deliverable
Target
Outcome
Interdependency/
Stakeholder
Lead
Timescale
RAG
on-going to
establish a
common
reporting method.
Appendix 4: Connecting Care Estates & Accommodation Plan 2018/19
Health & Wellbeing Priority: Creating and developing sustainable places and communities
1. Over the last 2 years a wide range of staff from Mid-Yorks Hospital Trust (MYHT), Wakefield Metropolitan District Council (WMDC), Age UK Wakefield
District (Age UKWD) and Carers Wakefield, have been co-located in the Connecting Care Hubs at Bullenshaw (Hemsworth), Waterton (Lupset and Civic
Centre (Castleford).
2. During April to November 2017, significant phase 1 accommodation changes and improvements were made to approx. 20% of the building space at both
Waterton and Bullenshaw, to enable other organisations to have a presence in order for them to join the newly re-designed multi-disciplinary teams
(MDT’s). These new MDT’s and care co-ordination arrangements commenced on 4th December 2017, whilst at the same time, MYHT ‘MY Therapy’
service was co-located with Adults Integrated Care, Social Care Direct team at Wakefield One.
3. Currently the MDT’s and new care co-ordination arrangements in both Bullenshaw and Waterton include support workers from Age UKWD, Carers
Wakefield, Mental Health Navigators, MYHT Community Matrons, OT’s, Physiotherapists, Dieticians, Therapy Support Staff, WMDC Adults Social
Workers and Care Co-ordinators, WDH and Pharmacists.
4. Phase 2 accommodation changes and improvements are now scheduled in from April 2018 to re-design the existing 80% of the buildings at Bullenshaw
and Waterton and to bring on a new satellite Connecting Care Hub at Holywell Lane, Castleford.
5. The Waterton Hub accommodation site on the West side of the district, is much bigger than the Bullenshaw Hub on the East, and is located in a prime
position, having easy transport access, links to other key services and the building also offers the necessary scope for new internal and external redesign, in particular extension of car parking facilities.
125
6. It should be noted however that geographically the East and South East of the district cannot be easily covered by one Integrated Care Hub and
furthermore, the Bullenshaw accommodation site, although well situated for access and links to other services etc., does not have the capacity to
accommodate all of the Health and Social Care workforce developments on Connecting Care planned for 2018/19. The estates plan therefore, includes
future provision of a satellite hub in Castleford.
7. The estates plan phase 2 entails significant re-design of the Bullenshaw and Waterton Hubs and the Holywell Satellite Hub, to include:
 Open work space environments;
 Reception and conference facilities;
 Access to new technology e.g. information screens, shared systems etc.
 Storage for small equipment items and assistive technology; and
 Additional car parking,
8. The timeline for the above accommodation changes and improvements across all 3x Connecting Care Hubs is as follows:
Accommodation
Waterton Connecting Care Hub
Bullenshaw Connecting Care Hub
Holywell Satellite Hub
Capital Works Commence
Ongoing
Ongoing
Ongoing
Anticipated End Date
TBC
TBC
TBC
9. Apart from the Connecting Care Hubs, further developments will be taken forward, to co-locate the Mid-Yorks NHS Trust “Single Point of Contact
(SPOC)” service with either, the Council’s “Social Care Direct (SCD)” team at Wakefield One or at the Waterton and/ or Bullenshaw Connecting Care Hubs
in Lupset and Hemsworth. This piece of work will run alongside the new Connecting Care developments, as it will be integral to the overall re-structuring
and re-design of the existing Connecting Care model.
10.The full utilisation of the new accommodation at all three Connecting Care Hubs, will provide significant opportunity for the new single leadership virtual
arrangements between MYHT Community Services and WMDC Adult Social Care to further co-locate large numbers of their staff. This in turn will
provide the necessary efficiencies from estates savings elsewhere, which will be required to fund the running costs of the 3 new hubs.
126
11.The additional accommodation at the 3 hubs will also enable other partner organisations to have a presence, as we further develop the new Connecting
Care model during 2018/19 and the anticipated full roll out of the Personal Integrated Care File (PIC), across all of the GP practices, within negotiated
timescales.
12.Further detailed and planned work between MYHT Community Services and WMDC Adult Social Care during April – November 2018 via their leadership/
chair of the local Joint Operational Delivery Group, will ensure a whole system approach to phase 2 of Connecting Care developments. It is envisaged at
this stage, this will encompass a wide range of other first contact and assessment services that as yet, are not integral to the new Connecting Care
arrangements and indeed other key organisations and professional roles that may need to be included in the Hubs for the first time.
13.Additionally, an Intermediate Care estates review will be required to be undertaken for winter 2018. This is as a result of the issues faced in 2017/18
with regards to the lift at Wakefield Intermediate Care Unit (WICU). An options appraisal will be developed and key actions will be taken forward by
November 2018 to support this key estates priority.
127
Appendix 5: Assurance Framework
The Mid-Yorkshire system dashboard impact indicators will be included within the business plan.
128
Outcome
People have clear
consistent and accessible
information to support
them to be healthier and
independent
People receive optimum
care
Support is provided by
compassionate enthused
people who feel valued
Community participation
is encouraged and
supported
Indicator
Number
129
Rationale
This indicator measures the degree to which people with health conditions that are expected to last for a significant
period of time feel they have had sufficient support from relevant services and organisations to manage their
condition. An improvement in this indicator would evidence the outcome described being achieved.
If people are identified sooner, managed and supported to be healthier and independent then this should lead to a
healthier population. As a result the number of people dying from conditions considered preventable should fall. If
this indicator is deteriorating then this would suggest there is a failing somewhere in the system.
Data requirements from ALL system partners
1
2
Mortality rate from causes
considered preventable
3
Emergency admissions for
acute conditions that should
not usually require hospital
admission
4
Emergency re-admissions
within 30 days
5
A&E attendance rate
6
Staff sickness rate
7
Staff satisfaction survey
(placeholder)
8
Patient satisfaction (GP
survey)
9
Number of volunteers across
all partners
10
Self reported quality of life
for Carers (18+)
11
Number of events occuring
at community anchors (to be
defined)
12
Proactive identification of individuals who need support is vital to ensuring that people are identified soon enough
to allow the system to provide the care they need. Not only is this highly beneficial for the individual, but it will
Under 75 mortality rate from
allow the system to manage conditions and care needs before an individual deteriorates and requires more acute
all causes
care. If the system is identifying people soon enough, and providing the required support, then the number of people
dying prematurely should decrease.
None - indicator can be calculated from Public Health
mortality data
13
Actual vs expected registers:
average distance from
expected (to be defined)
Many of the recognised disease registers have estimated numbers of expected prevalence. If the system is
successfully identifying people then the difference between actual and expected prevalence should reduce.
None - can be calculated bsaed on available register data
14
% of key sustainability &
resilience indicators
achieved across all partners
The long term success of the health and care system is dependant on being sustainable and resilient. Each partner
organisation will have it's own sustainability and resilience indicators that they monitor to ensure they are in a
good position. Working in an integrated way should enable many of the indicators to improve across the board.
15
Vacancy rate (including long
term illness)
A resilient and sustainable system will require a workforce that is operating at capacity. A high vancancy rate would
suggest a system that is more likely to struggle to respond in unexpected situations.
16
Number of delayed days
(DTOC)
An integrated system should be working well together to ensure patients can flow easily from one service to the next.
Delayed transfers of care indicate a delay in patient flow and a less integrated system.
People are proactively
identified to receive
appropriate support
Our system is integrated,
resilient and sustainable
Indicator Description
Proportion of people who
are feeling supported to
manage their condition
Some conditions are considered, in the main, treatable outside of the hospital setting. If the system is providing
optimum care we should see a reduction in the number of these types of admissions occuring.
This outcome is all about people receiving the optimum care, this means that they are receiving the right care, in the
right place at the right time. Sometimes an admission to hospital is entirely the right place for an individual to be. Readmission to hospital is a strong indicator of whether the system is providing optimum care, both in hospital and in
the community. In the vast majority of instances a readmission within 30 days means that care has not been
optimum.
Many people present at A&E with problems that can be resolved elsewhere in the health and care system. If the
system is providing optimum care to the population, then less people should be presenting at A&E as they are being
correctly treated elsewhere.
This outcome is about focussing on the health and care system workforce: without a happy, motivated and valued
workforce the standard of care provided will suffer and many other indicators will fail. Staff sickness rate is the best
indicator available to represent the general feeling amongst the workforce, as well as being a good indicator of the
resillience of the system.
An increasing level of staff satisfaction will indicate that the required outcome is being achieved.
A workforce that is compassionate, enthused and valued will provide better care and therefore patient satisfaction is
expected to rise. The suggested indicator only looks at GP survey.
Community participation not only improves the health and wellbeing on the individual but also contributes to the
health and care system, sometimes providing support roles that would otherwise require funding from elsewhere. An
increasing number of volunteers within partner organisation would indicate increasing community participation as
well as valuable support to these organisations
Carers are becoming an increasingly valuable part of the health and care system. In order to sustain people
receiving unpaid care in the community it is vital to look after and support the individuals providing this care. We
should be looking to improve the quality of life for Carers.
Community participation is more likely to occur if we have strong community anchors working within the District. If
the system is working to support these community anchors then the number of events occuring should increase.
None - nationally published indicator
None - indicator can be calculated from Public Health
mortality data
None - indicator can be calculated from SUS data
None - indicator can be calculated from SUS data
None - indicator can be calculated from SUS data
Each partner organisation required to submit total number
of whole time equivalents (WTE) and total number of sick
days - these will be aggregated to provide a system level
measure
This indicator will look to combine the staff satisfaction
survey carried out by each partner organisation - this will
need clearly defining after analysing the different survey
questions, but will require each organisation to submit
data from their survey.
None - data available nationally
Each partner organisation to submit the number of
volunteers working for them.
None - nationally published indicator
Community anchors to provide the number of events
occuring within the specified time period
Each partner organisation to submit the number of
sustainability and resilience indicators that they track, and
how many of them are being achieved. This will then be
aggregated to show the % achieved across all partners.
Each partner organisation to submit the total number of
whole time equivalents (WTE) and the number of vacancies
or long term sick. This will be aggregated to show a system
wide postion.
None - data available nationally
Glossary of Terms/Acronyms
We have tried to avoid jargon, but there may be some terms or abbreviations that you are not sure
about. Below is a useful list of other words or terms that might be helpful for the Integrated Care
Partnership Board to be aware of.
A
A&E Improvement Group: This is a sub group of the Mid Yorkshire Systems Oversight and Assurance
(MYSOA) Executive. The A&E Improvement Group is chaired by CEO of Mid Yorkshire NHSE Hospital
Trust Martin Barkley and the Board is responsible for delivering the requirements of the Local A&E
Delivery Boards. The A&E Improvement Group will be responsible for Leading A&E improvement and
recovery across Wakefield and North Kirklees. The A&E Improvement Group is responsible for
developing and approving Wakefield’s Winter Plan, Leading A&E recovery; Implementing the Next
Steps on the NHS Five Year Forward View, Implementing the five mandated improvement initiatives
that relate to streaming, flow and discharge. Initially this will all be about recovery of the 4 hour
target but will also be working with STP groupings on the longer term delivery of the Urgent and
Emergency Care Review; Developing plans for winter resilience and ensuring effective system wide
surge and escalation processes exist and supporting whole-system planning (including with local
authorities) and ownership of the discharge process.
Acute Commissioning: This workstream brings together commissioners across North Kirklees and
Wakefield CCG’s to commission acute care more effectively. Pat Keane leads this work on behalf of
both clinical commissioning groups.
Acute healthcare: Medical and surgical treatment usually provided in a hospital setting. See
Secondary Care.
Alliance Agreement: In August 2017 13 organisations across Health and Social Care in Wakefield
signed up to an alliance agreement to improve outcomes of patients. The Agreement commenced in
August 2017 and is an 18 month agreement that ends in March 2019. The scope of services within
the agreement focuses on out of hospital community care services working together differently. This
brings approximately £70m worth of services together. The agreement includes, the vision,
objectives and work programme for the Integrated Care Partnership Board who is the Board which
brings this work programme together.
ANP: Advanced Nurse Practitioner
130
B
BCF: The Better Care Fund (BCF) is a programme spanning both the NHS and local government which
seeks to join-up health and care services, so that people can manage their own health and wellbeing,
and live independently in their communities for as long as possible. The BCF has been created to
improve the lives of some of the most vulnerable people in our society, placing them at the centre of
their care and support, and providing them integrated health and social care services, resulting in an
improved experience and better quality of life. Wakefield has to develop a BCF plan which is
approved by our Health and Wellbeing Board. When this is approved by NHS England the CCG and
WMDC can enter into pooled funding arrangements to support the way care is commissioned in
Wakefield.
C
CC2H/ CCTH: Care Closer to Home
CCG: CCG stands for Clinical Commissioning Group. In April 2013, the CCG took on the responsibility
of commissioning the majority of secondary and some community healthcare services for Wakefield
patients. The CCG is an NHS organisation which commissions quality services that are fair and
equitable and that will improve all our patients’ experiences of the health and care they receive.
Clinical: Relating to patient care e.g. clinical evidence, clinical practice.
Clinician: A health professional, such as a family doctor, psychiatrist, psychologist or nurse, involved
in clinical practice.
Clinical pathways: Medical guidelines or other management tools based on evidence based practice
for a specific group of patients which improve health results.
Commission: To decide on behalf of a local population what type, quantity and quality of services it
requires, obtain the services from service providers and monitor the way they are provided. See
Clinical Commissioning Group, Primary Care Trust.
Commissioner: The person or body who decides on behalf of a local population what type, quantity
and quality of services it requires, obtain the services from service providers and monitor the way
they are provided. See Clinical Commissioning Group, Primary Care Trust.
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Connecting Care +: This is Wakefield’s branding for integration of care in our system. The Connecting
Care + model is designed to dismantle divides and improve the co-ordination between separate
groups of staff and organisations. It involves redesigning care around the health of the population,
irrespective of existing institutional arrangements. It is about creating a new system of care delivery,
supported by an effective and robust financial and business model. This means developing and
embedding innovative patterns of engagement throughout a system that currently exists in separate
parts. The promotion of public health, effective deployment of multidisciplinary teams, ease of
access for the public to services, and the best use of technology are all elements which cannot
operate in isolation. These must be utilised and delivered in collaboration, in order to ensure the
best patient benefits. Connecting Care + will see care delivered closer to home, fewer trips to
hospital, improved coordination of support, better access to specialist care in the community, and a
promotion of public health and wellbeing and the tools for greater self-care.
CQC: Care Quality Commission. This is an organisation funded by the Government to check all
hospitals in England to make sure they are meeting government standards and to share their
findings with the public.
D
DToC: Delayed Transfer of Care – NHS England has asked all areas to achieve a target for their Health
and Wellbeing Board footprint of 3.5% in 2017/18.
E
Emergency care: Treatment for medical and surgical emergencies that are likely to need admission
to hospital.
Emergency department: Also known as ‘Accident & Emergency.’ A service available 24 hours a day,
seven days a week where people receive treatment and/or stabilisation for medical and surgical
emergencies.
Emergency surgery: Surgery that is not planned and which is needed for urgent conditions. This
includes surgery for appendicitis, perforated or obstructed bowel and gallbladder infections. It is
also known as non-elective surgery.
F
Finance: The money/ budget that an organisation has and the management of it.
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G
GP: A doctor who treats a variety of illnesses and diseases, providing preventative care and health
education for everyone. Usually, but not always, based in the community.
H
Health and Wellbeing Board: Wakefield’s Health and Wellbeing Board is Chaired by Cllr Pat Garbutt.
The Health and Social Care Act 2011 brought fundamental changes to the way we plan and deliver
health improvements within the Wakefield district. The Act created a statutory function for every
area to develop a Health and Wellbeing Board which is a public meeting. Organisations across health
and social care are tasked with working together through a Health and Wellbeing Board to ensure
that there are local plans in place to protect and improve health outcomes and where necessary to
provide the best available Health and Social Care. The board must develop a Joint Health and
Wellbeing Strategy that gives an overview of the key challenges and how the partners are going to
agree to work on these together, which must be based on the findings of the district Joint Strategic
Needs Assessment. It should provide the framework for the individual agencies to develop
commissioning and delivery plans which will together meet the needs of the district. It must
encapsulate some joint principles by which all partners agree to operate.
Healthcare: The diagnosis, treatment, and prevention of disease, illness, injury, and other physical
and mental impairments in humans.
Health and Wellbeing Plan: a district wide plan agreed with the local council to improve the health of
the district over a set period.
I
IAPT: Improving Access to Psychological Therapies
Integrated Care Systems: In February 2018, NHS England and NHS Improvement published the new
planning guidance for 2018/19. The guidance describes that
We will reinforce the move towards system working in 2018/19 through STPs and the voluntary rollout of Integrated Care Systems. Integrated Care Systems are those in which commissioners and NHS
providers, working closely with GP networks, local authorities and other partners, agree to take
shared responsibility (in ways that are consistent with their individual legal obligations) for how they
operate their collective resources for the benefit of local populations. We are now using the term
‘Integrated Care System’ as a collective term for both devolved health and care systems and for
those areas previously designated as ‘shadow accountable care systems’. An Integrated Care System
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is where health and care organisations voluntarily come together to provide integrated services for a
defined population. Further details can be found using the following hyperlink:
https://www.england.nhs.uk/wp-content/uploads/2018/02/planning-guidance-18-19.pdf
Inpatient: A patient who is admitted for a stay in hospital, usually for 24 hours for treatment or an
operation
Integrated Support and Assurance Process (ISAP): This is a process introduced by NHS England that
every area that is considering commissioning a complex contract must adhere too. It provides
assurance for NHSE, NHSI and other regulators that complex procurements have developed the
appropriate evidence to proceed with the complex are that is being commissioned. This process is
being used now for the commissioning of new models of care across the country.
J
JODG: Joint Operational Delivery Group, this is a forum chaired by Rob Hurren as Director of
Integrated Care at Wakefield Council. It brings together all partners across Connecting Care +
together to work through the operational challenges of developing the Connecting Care Hubs, the
Personalised Integrated Care File and is responsible for reviewing operational service delivery that
supports integrated care.
JSNA: Joint Strategic Needs Assessment. The JSNA and joint health and wellbeing strategy allow the
health and wellbeing board to analyse the wider perspective of wellbeing, helping local partners on
the health and wellbeing board reach a consensus on the priorities to be addressed across the
system, and how to make best use of collective resources to achieve them. No single organisation
can do this alone, but a shared sense of priorities, built on confidence and trust and supported by a
robust evidence base, can help partners work together and focus in on key issues that really matter
locally. In Wakefield our Public health team lead on the development of our system’s JSNA- this can
be found here at this website http://www.wakefieldjsna.co.uk/
M
MCP: Multispecialty Community Provider (MCP) An MCP is what it says it is - a multispecialty,
community-based, provider, of a new care model. It is a new type of integrated provider. More
information published by NHS England on MCP’s are available at https://www.england.nhs.uk/wpcontent/uploads/2016/07/mcp-care-model-frmwrk.pdf
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Medicine: A specialty that covers a wide range of conditions for which people are admitted to
hospital. Many focus on particular organs (e.g. the heart) or diseases such as cancer. Medical
specialties include: cardiovascular medicine, dermatology, endocrinology and diabetes,
gastroenterology, genito-urinary medicine, oncology and rheumatology to name a few.
MYHT: Mid Yorkshire NHS Hospitals Trust – The hospital trust for the Wakefield area which provides
community services, elective and acute services for the District.
MYSOA: The Mid Yorkshire Systems Oversight and Assurance (MYSOA) Executive is a whole Mid
Yorkshire system of executive level partners working to take ownership and drive the development
of resilience planning and transformational change in the delivery of health and social care across
the local Mid Yorkshire system, aligning organisational priorities and plans to deliver the best
possible outcomes for patients. The MYSOA is Chaired by the Senior Responsible Officer Jo Webster
from Wakefield Clinical Commissioning Group. The executive will have four main sub-groups;
 A&E Improvement Group;
 Panned Care Improvement Group;
 Executive Improvement Board;
 Clinical Leaders Forum
N
Integrated Care Partnership Board: (ICP Board) This Board is chaired by Dr Ann Carroll and the
purpose of the board is to create a new system of community care delivery, supported by an
effective and robust financial and business model. The partners of the ICP Board have signed up to
an 18month Alliance Agreement to support this work programme. The ICP Board brings over £119m
of services together through this alliance agreement.
O
Outpatient: A patient who attends an appointment to receive treatment without actually needing to
be admitted to hospital. Outpatient care can be provided by hospitals, GPs and community
providers and is often used to follow up after treatment or to assess for further treatment.
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Overview and Scrutiny Committee (OSC)/Health Overview and Scrutiny Committee (HOSC): The
committee of the relevant local authority, or group of local authorities, made up of local councillors
who are responsible for monitoring health and social care.
P
PHB: Personal Health Budget
Patient pathway or journey: This is the term used to describe the care a patient receives from start
to finish of a set timescale, in different stages. These can be
Integrated care pathways which include multi-disciplinary services for patient care.
Performance: The achievement and outcome of a given task against known set of standards, usually
around completeness, cost and speed. In a contract, performance is deemed to be the fulfilment of
an obligation.
PIC: Personalised Integrated Care file. The Personal Integrated Care file “PIC” has been developed by
Mid Yorkshire Trust using SystmOne to enable the sharing of key demographic, referral and care
coordination information across the multidisciplinary health and care teams working in the
Connecting Care hubs. Wakefield Council agreed to purchase a SystmOne unit to enable the care
coordination team and social care staff to access the PIC file as the central source of information
regarding services are working with a Wakefield resident. The requirement for the PIC file was
developed from our learning from a paper based triage service which had previously been used in
the hubs. SystmOne was selected as a pragmatic option for sharing data across the connecting care
team due to the wide use in general practice and in MY community nursing and therapy services.
The PIC has been developed to allow GPs using SystmOne to e-refer to the hub services and hence,
subject to consent, for appropriate patient data to be shared with the coordination team to better
manage care of a resident; by using SystmOne GPs will be able to see the detail of services engaging
with a patient. The PIC file does not replace any organisations existing management system, our
aims to develop integration between key systems at a later stage in the project. At present we have
not been able to develop the system for access by GPs using EMIS, this is dependent upon future
integration work on GP systems being led by NHS digital and NHS England.
Planned Care Improvement Group: A sub group of the Mid Yorkshire Systems Oversight and
Assurance (MYSOA) Executive. The forum is chaired by Pat Keane who works across both Wakefield
Clinical Commissioning Group and North Kirklees CCG. In accordance with the requirements of
transformation and sustainability this group will be responsible for secondary prevention, the
management of long term conditions and delivering effective pathways of care across primary,
community and secondary care.
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Primary care: The first contact a patient has with local healthcare in their community, usually a GP,
dentist or optician. (i.e. not secondary care, which is hospital based).
Q
Quality: The degree to which health services increase the likelihood of good health outcomes and
are consistent with current professional knowledge. There are often six dimensions to quality:
safety, effectiveness, patient centredness, timeliness, efficiency and equity.
S
Secondary care: Healthcare services delivered by medical or other specialists, usually in hospitals or
clinics, that patients have been referred to by their GP or other primary care provider.
Stakeholder: People and organisations with a shared interest in an issue, either because they may be
affected by it or be able to affect a decision about it.
Surgery: Medical specialty where surgeons specialise in operating on particular parts of the body or
to address specific injuries, diseases or degenerative conditions. The main areas of surgery are
cardiology, ear, nose and throat (ENT), general, oral and maxillofacial, orthopaedic and trauma,
paediatric, plastic and urology.
Sustainability: Ensuring a service can operate properly, well into the future, in a way that is safe, of a
high standard, appropriately staffed and which makes the best use of the resources available.
W
Workforce: The people on an organisation’s payroll.
Y
YAS: Yorkshire Ambulance Service
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About Wakefield Connecting Care+
Connecting Care+ is made up of local health, social care and voluntary and
community sector organisations from across the Wakefield district. These
organisations work together as partners to deliver health and social care
integration to deliver innovative methods of care to local people.
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