Locality Events Summary, July 2014
Background
In July 2014 one event was held in each of the four GP locality areas. The aims of
the events were:

to introduce the latest thinking about the Better Care Fund strand of Keeping
People Well in their Community

to provide an opportunity for providers and commissioners to work together on
designing outcomes and measures of success all parties can work towards

your chance to tell commissioners what you need to be able to deliver

to give an opportunity to network with other providers
Following a presentation delegates completed 2 exercises on tables of
approximately 10 people. Exercise 1 was about reviewing the outcomes and
indicators. Exercise 2 was changed after the first event. At the first event the
exercise was to network with providers who you hadn’t met before. For subsequent
events Exercise 2 was to discuss who potential partners could be to deliver the
outcomes of Keeping People Well in their Community.
Below is a summary of the key points at each event and some common issues that
came up at all the events. The full write up can be found at the end of this paper.
The information from the events will be used to inform the development of the
Keeping People Well in their Community outcomes framework and identify how
commissioners can support the health and wellbeing provider market to be ready to
deliver against the new Keeping People Well in their Community outcomes
framework.
We encourage you to use the event contact list to contact people who you may want
to start working with anyway. Please do also complete and return the Keeping
People Well in Their Community self-assessment tool. This tool should be helpful for
your own organisational development and will inform commissioners about what
kinds of support providers need to prepare for delivery.
General Points from all of the events
Patch sizes make a difference to how this ambition can be delivered. If services only
work city wide then they don’t always have the necessary local knowledge to deliver
these outcomes.
Having the right information in the right places in every community that people can
then access is vital.
There was a misunderstanding that because the outcomes don’t specifically refer to
groups such as “people with a learning difficulty” or a “mental illness” that the
Keeping People Well in their Community outcomes are excluding these groups. On
the contrary, the outcomes are for anyone at risk of declining health and wellbeing
who are not currently users of acute health and social care services.
There appeared to be some misunderstandings around risk stratification. One
misunderstanding was the GP based risk stratification tool, the Combined Predictive
Model (CPM), was the only risk stratification approach. The CPM tool can be
combined with other sources of data (both knowledge of practitioners and other data
sources) to refine how we can identify who could benefit most from some early
support to sustain health and wellbeing. Another was that the CPM tool is only used
for patients at high risk of hospital admission. The CPM can be filtered to reach low
risk people early. It was also felt that risk stratification was a function not necessarily
an outcome.
GP Practices need, and on the whole want, a one-stop-shop / single point of access
for all social / non-medical issues. There are too many different services that change
too quickly for GPs to remember them all. However, GPs and other providers of
health and wellbeing services do need ways of networking and working together to
make best use of what we have in each area and support people to be healthy and
well.
Short-term funding is a hindrance to developing sustainable community based health
and wellbeing support for people.
Information sharing between providers and local people who are working to support
similar groups needs to be ironed out to ensure the efficient use of resources.
Suggested Indicators
Social interaction
Quality of life increases for patients and carers / happiness score
Reduction in residential care home admissions
Increase in people being able to die at home / more palliative care at home
Number of people who have a holistic care plan, with goals that have been reviewed
Provide more support workers in the community (additional to care closer to home
teams) – indicators of achievement
Reduction of hospital admissions/re-admissions / increase in successful discharges
after 60 days.
Reduction in complaints from patients
School attendance
Event 1: Hallam & South Locality
2-way communication between GPs and all agencies that they refer into should be
an operating principle.
Commissioners need to talk to “real” GPs and not just the Clinical Commissioning
Group GPs.
Provide continuity of care to people – small multi-disciplinary teams – with GP’s
Event 2: North Locality
Concerns about the disparity of services between practices – due to the varied
voluntary community and faith sector services in this part of Sheffield.
Local knowledge needs to be used alongside the risk stratification tool to ensure that
we reach the right people (concerns that the tool alone does not pick out the right
people).
Read codes (for GP recording system) need developing for specific indicators so that
the outcomes can be effectively measured.
Use the results of the evaluation of the SOAR model to inform the design of Keeping
People Well in the Community.
Need more rapid responders for those teetering on the edge of crisis.
More integrated working with community matrons and social services, e.g. social
workers working alongside community nursing teams.
Event 3: Central Locality
Make better use of assets – GPs surgeries are empty out of hours, could the spaces
be used for community activities?
Need better communication from the hospital re patients who have been discharged
to ensure better care at home can be provided.
Local inform and advise – need to catch those people who don’t know what they
don’t know!
Build on the learning and make use of the resources that housing providers have
and the community organisations that are already supporting people’s health and
wellbeing.
Event 4: West Locality
Less history of partnership working in this area as most of the locality has not had
regeneration funding or Health Communities initiatives.
Need coordinators of non-medical support in surgeries
Potential Delivery Partners – Zest, SOAR, Bradfield Parish Council, Stocksbridge
Parish Council, Support 55 Housing Support, S4LC, Activity Sheffield, CAMHS,
Probation, DACT, CICS
Ideas – adopt a granny / granddad, advertise lunch clubs, target the lonely as they
do not access benefits / services / care. Identify lonely people by unplanned
admissions and follow them up in the community (link to unplanned admissions
Direct Enhanced Services contract GPs have), health visitors for older people as well
as young parents, increase capacity in CICS.
Next Steps




There will be one or two “mop-up” events for providers who couldn’t attend
the July workshops
The self-assessment tool will be circulated to health and wellbeing providers
in August. This will enable providers to gauge their readiness to deliver the
Keeping People Well in their Community outcomes discussed at these events.
Included in the self-assessment will be the opportunity for providers to identify
any support you feel would be useful in improving your ability to deliver.
Keeping up to date – we will send progress updates to everyone who
attended the events and will be in touch directly with anyone who expressed a
desire to be more actively involved in developing this piece of work.
In the meantime we would encourage you to make contact with people on the
contact list from the events where you have identified that there may be
benefits in working together.
APPENDICES – WRITE UP OF EVENT FLIPCHARTS
WRITE UP OF HALLAM & SOUTH LOCALITY KEEPING PEOLE WELL IN THEIR
COMMUNITY WORKSHOP
Flipchart 1
How can we measure if there is a decrease in medical advice being sought?
Risk stratification is good / positive tool that we are already using. We don’t another
tool. What is social services assessment / risk tool? What about those without a
high risk score?
How do we get people to ‘take responsibility for their health and wellbeing’? What
about at risk people who refuse interventions even when offered?
How do we keep up-to-date and abreast of all the various support workers and
services available?
How can investment be made in community assets / services to support those at
risk?
Other outcomes: Hospitals to take responsibility for ensuring that patients are
discharged in a fit (enough) state, with their correct medication and adequate
support.
We all seem to be sounding quite cynical. Does this in itself tell us something?!
Flipchart 2
Risk Stratification: there will be a lot of people that this will not cover / identify. Need
to flag up non-clinical cases.
Sort and Support and Community Asset Development – do we need these if we have
a central point of contact for information and advice?
Ideas: outcome for local inform and advise – look at how it’s worded, apportioning
responsibility.
The outcome indicators need to be more inclusive.
Flipchart 3
Language / acronyms
Ask the “real” GPs
Criteria for assessing community services.
Flipchart 4
What do you think of the suggested outcomes?
Risk Stratification

Feel that this is too ‘reactive’

Patients don’t have a ‘rating’ until something has happened. It’s the people
that haven’t yet reached ‘crisis’ that we need to support with preventative
techniques as well as those who need support to prevent escalation.

Need to avoid rigidity with use of the tool (not black & white)
Local Inform and Advise

Internet access – increasing the availability of info (can be positive but also
presents problems when people self-diagnose)

Linking Home Care Provision to Community Support Practice in Sheffield. To
support people at risk of becoming isolated (e.g. recently bereaved)

A lot of duplication e.g. with care plans, patient info. Home care / GP records
should be more translatable. E.g. service users / patients have to tell the
same information to carious different parties. There should be joint-working /
info sharing.
We need more Community Support Workers!
Flipchart 5
Always need 2-way communication. This should be an operating principle, esp. re
referrals and getting feedback.
Life Navigation – important for short period of time appropriate support, e.g.
bereavement.
The role of Community Support Workers is variable. Does provide companionship
over a short period.
Need a way to be able to access information re what help is available easily. There
is too much information online. Information should be in the places that people
congregate in a community – pub, post office, library.
Self-Care / Wellness Plan

Outcome indicator: Number of people who have holistic care plan – with goals
and has been reviewed.
Risk stratification tools

We need a more sophisticated approach. Use the combination of different
tools to decide who is referred.
NORTH LOCALITY WORKSHOP WRITE-UP
Commissioning
Have / want to be involved – Space – lack of?
Need to identify within GPA’s – rent, electric etc. overhead costs.
Need to be involved knowing what’s coming, definitely need to be involved.
One HUB – GP practice or other community centre
Need coordination every step of development, can we utilise rooms in the LIFT
practices by a reduction in the rent for the spaces for community groups?
Transport; key to access – needs to be part of discussions
Partners / One SPA / GP’s + SOAR – Partnership
Referral process others should refer too.
Third Sector / Voluntary Sector / Charity / Housing / Faith
Support & Guidance, protected time, which means funding
Delivery partner? SOAR + another GPA? Ecclesfield
Influence design
Risk Stratification
-
Having done lots of work on risk stratification, we worry that the wrong people
are being targeted.
-
Is it robust enough
-
Using local knowledge (GP’s/District Nurses/Social Care) is invaluable.
-
Community infrastructure works together to provide a cohesive service
-
Concerns re disparity of services between practices
-
School attendance as an overarching outcome of the whole project
-
Reducing frequent A&E attendance
-
Information sharing is critical
o Without it, it will fall over
-
Design principles – whatever the solution, build around care
Exercise 2 Partnerships – depends on the ask
-
Certainly ‘yes’ to key delivery partners, but at what scale depends on what’s
specified & what resources are available
-
Need to be involved both in the design of the specifications – co-design + also
delivery/design of the ‘solution’
-
The outcomes are right – major challenge is pulling together all the
organisations involved
-
Need to be able to understand who does what & a central point to feed into
-
Somebody needs to be in charge – an advocacy service – single point of
access
-
Co-ordinate services around PH – ‘One Stop’ principles
-
Need to connect with independent living solutions & intermediate care
-
What’s missing is the link with more intensive primary care support (medical,
nursing & therapy)
-
Key issue is short term funding doesn’t help
-
Accessibility
o Information
o Transport
o Barriers
Quality of life – how many social interactions – tracking
Networking – preventing duplication – finding gaps
Grassroots (vs) Strategic
Risk Stratification
Share information across Health & Social Care
Shares is the outputs of risk stratification so that organisations can work together
-
Understanding of outcomes – the individual situation/outcome indicator
-
MDT Meeting / Measurement of risk score
Challenges
-
Sharing of relevant information
-
Risk stratification needs to be up to date
-
Language – common
-
Reduction in GP appointments
Local Information & Advice
SPA - for social care
SOAR – Model good
Triage
Outcomes – five
Outcome indicators
Difficult to measure (GP’s)
(NOT READ-CODED)
Would have to measure before service is introduced; to measure difference
SOAR evaluation
Risk stratification tool - ? redesign
Crude scoring system
LTC – Annual Health check anyway
Children ? scores based on?
1) ? Correct risk measures
Local inform & advise – housebound patients –
Changing public opinion of where they need to access.
Outcome – Increase on contact with SOAR for example
Barrier – LIFT building rent charges – discuss with CCG.
Utilisation of GP practices OOH / weekends.
One point of access –
Social spa
GP / DN / Self-referral
Other outcomes – more patient focussed on well being
FA outcomes measured - ? better. Longer GP appointment
required
MDT – social & health care – sharing information – risk patients.
CENTRAL LOCALITY WORKSHOP WRITE-UP
Exercise 2
Breaking down social isolation –
Sue Walker – SCC – off the shelf interval
Targeting particular issues: Disability & Access + Adult Literacy
Outcomes & Indicators
What do we think about the suggested outcomes (passport Makaton – sign
language)
The headings are open to misinterpretation, need more clarification i.e. sort &
support.
Written justification is not an outcome – it’s slightly process’ey
Ensuring those ‘most vulnerable’ are captured in this e.g. disability/mental health.
Housing providers (great places)
-
Low level support
-
Financial + advice services – re-assurance
-
Pass on/share case information
-
Practice to pay to low level support
-
Second someone to work in the housing team.
-
Winter well-being checks are already been done
-
We support food banks (+we can deliver in snow)
-
Really interested in supporting people with MH difficulties – isolation
Darnall Wellbeing Project
-
Use what we are doing – learn from pilot on health interventions
-
Bring pool of resources to support patients in long term planning
-
Short to medium term (appropriate) increase in use of primary care services.
R.S – needs to target all PA throughout all functions, are these specific target
groups?
Awareness & commissioning of services
Info to the night person, including format, language
One point of contact
Establish commissioning group such as health champions to speak & work with rest
of commissioning team:
-
Links to other services
-
Guidance & Advice
Analysis needs to happen on those affected by changes, not a blanket approach,
people need to be able to take responsibility, and some people are not able to.
Connecting people
-
PA
-
Community forums
-
What do people want?
-
Connecting policy
-
Community Support Workers
-
Sharing knowledge
-
Engaging volunteers – Time limited
-
Skills / knowledge
Confidence (Self Manage)
-
Physio – very important
-
Proactive calling
-
PAM
Life Navigators?
-
Function, how?
-
Communication a huge issue even for providers + workers in the sector let
alone the service users.
Important for right level of person to deal with issues taking resource from GP time,
possibility of information drop in GP surgeries – but people need to know about it for
consistent use.
Issues – so many places to refer to, different referral forms, GP Practices under
increasing pressure, need one stop shop – know all services, best ones for different
people
Need care co-ordinator – MH issues very important, need more support from
community nursing in dealing with chronic disease to prevent admission problems –
staying in hospital too long because assessment to get out not there OR sent home
too soon.
Need support workers; more intermediate care – more residential support between
hospital & home.
All age groups need support; not just the elderly.
Impact of adverse social media on social isolation
Technology can be intimidating, local understanding is important.
Need to agree what told are used, even use them & monitor our own use of!
People move around, society is not static.
Commissioners can & should own services, names, telephone numbers & materials
(providers come & go, but telephone numbers can stay the same)
-
Confidentiality – who will see / know what about clients / patients (re: risk
stratification)
-
Bed blocking/discharge – will this be included as outcome or indicator –
readmission rates
-
GP’s seeing hospitals discharging very quickly – not communicating well –
patients being re-admitted
-
Needs central person to co-ordinate, could they be based at GP’s? Needs
resourcing
-
Redirect money from care trust to community mental health services
-
Bring sport into schools – every Wednesday afternoon
-
Helpline – central point of information / someone to talk to
-
Social events, using volunteer skills & power.
-
Better use of physical assets e.g. GP surgery buildings empty out of hours –
put community support services in there – have an outcome which sets a
target for this
-
Housing big issue – not enough stock which is suitable for need – keeping
people in hospital because of housing needs adaptations etc.
-
Community shops/facilities – volunteers?
-
Need a common framework – 5 Ways to Wellbeing
-
Reaching people who don’t normally engage – how do you measure this?
-
Got to release resources before, have made savings on acute care – Chicken
+ Egg!!
***Link with wellbeing strand of Health & Wellbeing Strategy***
Think about suggested outcomes
-
Good in theory – depends how it works in practice
-
Very generalised – not person centred
-
Highly dependent on peoples compliance & ability
Release resources from acute care
-
Provide more intermediate care beds & facilities
-
Can be discharged from acute bed
-
Ensure discharges – limits re-admission
Other outcomes / suggestions
-
Make more use of matrons
-
Rapid responders
-
More integrated working with social services, e.g. social workers working
alongside nursing teams
-
Provide continuity of care to people – smaller teams – with GP’s
-
Provide more support workers in the community (additional to care closer to
home teams) – indicators of achievement
-
Reduction of admissions/re-admissions
-
Less complaints from patients
WRITE UP OF WEST LOCALITY KEEPING PEOPLE WELL IN THEIR
COMMUNTIY WORKSHOP
Flipchart 1
Exercise 1: Outcomes
Realistic outcomes that can be measurable so that delivery doesn’t fall at the first
hurdle.
Risk Stratification tool – does it need to be in the outcomes? Is it really a function /
operating principle?
Community Asset Development – this infrastructure does need to be in as an
outcome. Need to provide consistency in message to tackle priorities.
Local inform and advise – need to catch those people who don’t know what they
don’t know!
Offer those who struggle to access services / information to tackle health
inequalities.
Employ health visitors for older people as well as young parents.
Exercise 2: Partnerships
Need coordinators in surgeries.
NHS data support access.
Potential Partners – Zest, SOAR, Bradfield Parish Council, Stocksbridge Parish
Council, Support 55 Housing Support, S4LC, Sheffield International Venues (SIV)
Flipchart 2
Exercise 1: Outcomes
Too idealistic – need more ground level support, i.e. meals on wheels / bathing
services
Education – make sure everyone has the right life skills to lead a healthy life / good
nutrition. Adult learning. Community leisure facilities.
Social interaction – should be an outcome indicator
Reduce unnecessary bureaucracy and administration.
Flipchart 3
Exercise 1: outcomes
Patch sizes make a difference to how this can be delivered. If services only work
city wide then they don’t always have the necessary local knowledge to deliver these
outcomes.
Most of West Locality hasn’t had Healthy Communities programme and other
programmes that have provided opportunities for partnership working to develop and
mature.
Communication – need to link in with each other better.
Risk Strat and Life Navigation already happened in different organisations
Exercise 2: partnerships
Keep the voluntary sector involved – e.g. Shelter who are delivering health work and
outcomes as part of holistic support work.
Flipchart 4
Exercise 1: outcomes
Suggested outcomes
To improve care at home
Reduce contact with GP? How to measure?
It is very hard to prove a reduction in hospital admissions. A better outcome would
be quality of life increases for patients and carers.
Ideas – adopt a granny / granddad, advertise lunch clubs, target the lonely as they
do not access benefits / services / care. Identify lonely people by unplanned
admissions and follow them up in the community (link to unplanned admissions
DES)
Workers / Community Support Workers need to be measured on contacts with lonely
people per day.
GPs to give lists of their known lonely people to CSW and they contact them.
Quick response and appropriate level
Increase capacity in CICS
Community activities: lunch clubs, choir, chickens, art & craft, outings, allotments,
visits to schools, IT help, volunteer care awards, SPA [NHS Single Point of Access]
need to be aware of voluntary organisations
Suggested Indicators:
Happiness score
Join older lonely people with young families – benefits both ways
Number of eggs / days of chickens [!]
Reduction in residential care
Increase in people being able to die at home / more palliative care at home
Exercise 2: Partnerships
Activity Sheffield, Zest, CAMHS, Probation, DACT, CICS
Need a SPA for social isolation / housing / volunteers / benefits / community matron /
loneliness – must have an easy referral system (not internet) and inc self-referrals.
This commissioned by Better Care Fund and locality based and have this sort of
person in a GP practice.
Have a Direct Enhanced Service for lonely people