Sarah Monks
Hello and welcome to today’s primary care podcast. My name is Sarah Monks, Community Health Services Nurse Lead for North East and Yorkshire, Queens Nurse and Churchill Fellow.
Today we will be discussing one of the hot topics at the moment, neighbourhood health and integrated neighbourhood teams, ahead of the publication of the much awaited 10 year health plan. Neighbourhood health and integrated teams is not a new concept and in one form or another this has been around for some time.
Policymakers and practitioners have long talked about the need for more joined-up proactive care, with flexibility to respond to local need. Within the NHS, there is an increasing focus on the role of places in neighbourhoods, as articulated in the 2022 Fuller Stocktake.
The government has emphasised the importance of this shift in its manifesto commitment. At least two of the Secretary of State key big shifts be in hospital to community and sickness to prevention rests on better relationships within our communities, going beyond the medical model and building a stronger understanding of the NHS’s role in the wider determinants of health.
The recently published neighbourhood health guidelines recognise the urgent need to transform health and care systems and deliver more care at home or closer to home, improving people’s access experiences and outcomes, and building a sustainable health and social care delivery model.
This can be understood at 2 levels: Firstly, how communities can be enabled to take back power of their own health and well-being, particularly in areas with the greatest levels of deprivation and a lack of social infrastructure.
And secondly, how the NHS needs to be an effective partner in this change, including a partner in broader community development and in addressing the social determinants of health and well-being, working with local government and voluntary community and social enterprise partners.
So I am really honoured to be joined today by some real innovators in the North East and Yorkshire region, tackling the challenges around neighbourhood health.
Joining me today are:
- Dr Nat Martin, GP and modern general practice peer ambassador
- Dr Helena Ebbs, Clinical Director of Integration, Humber and North Yorkshire Integrated Care Board or ICB
- Dr Tom Holdsworth, GP and chair of the Sheffield PCN clinical directors’ group
- Jackie Wilkinson, Ageing Well Practitioner within our NHS West Yorkshire ICB
- Emma Kergon, Portfolio Lead for Anticipatory Care with Bradford District Care Trust, also within the West Yorkshire ICB.
A wonderful panel with a broad range of perspectives and experiences supporting what will be an interesting and rich discussion.
To start us off, we must acknowledge the many ways neighbourhood health has been defined but now let us consider what it means to our guests.
Perhaps you could start us off Nat with your thoughts on what neighbourhood health means to you?
Natalie Martin
Hi so to me I would say that it’s about having that oversight of your whole community, understanding what is going on for the people that you look after – both from a data point of view but also from their individual stories, and about working with other members of the primary care team to bring together that information and to help bring initiatives to support that community.
For me, a big thing about it, is looking at preventative medicine and how we can stop things before poor health develops.
Sarah Monks
Oh, wonderful, thanks Nat. Would you like to come in, Tom, on what neighbourhood health means to you.
Tom Holdsworth
We’ve done a lot in neighbourhood health, within townships, one PCN and then across the PCNs in Sheffield, and I think for me, it’s something about things being really delivered locally; and a lot of that is about relationships between practitioners working in a in a patch.
So a lot of it is about developing those relationships between different organisations, and to do with developing less formal pathways, so that, you know, we have less hand-offs, less referral forms, and that really, care feels a lot more like working alongside your practice nurse in a practice. So I would never ask my practice nurse to look at referral form when I’ve got a patient with a leg ulcer, I go and knock on her door and say, ‘can you help me out with this?’
And I think that integrated neighbourhood working should feel a lot more like that for people.
I think it’s also about just giving people the permission to do the right thing. So the system’s often not very good at doing that. You know, enable people with good relationships working in local patches to just get on and do the right thing for people, and I think I totally agree with Natalie about this, this idea that it should be population health-led and it should be about keeping people well. So we’re, you know, we spend a lot of time focusing on illness and treating illness, and perhaps not enough time on creating wellness and keeping people well.
Sarah Monks
Really powerful thought there, Tom, around creating wellness. Helena, do you like to come in on that?
Helena Ebbs
Yeah, thanks I mean, I completely agree with Tom. I think what Tom has just highlighted is, it’s a way of working. So when we talk about neighbourhood health, you know, there’s a sort of infrastructure thing that we think about, you know; who are the organisations working in each neighbourhood, whether that’s GP practices or pharmacies or opticians or adult social care and on and on and on. And they are our neighbourhood health organisations.
But what we really talk about when we’re focusing on neighbourhood health is this approach. It’s this way of working. And it’s particularly the integrated way of working and I think to most of us who interact with health and care services, most of our interactions are relatively simple.
What we need to do in a neighbourhood health approach is focus on what’s complex. In particular, those people who are in contact with multiple different services, multiple different organisations, or who aren’t in contact with us but really would benefit from that.
So for me, the focus on neighbourhood health is not just about organisations working in your neighbourhood, which is as important as anything – it’s about this way of working that Tom’s described and that’s alluded to as well. This integrated way of working where we’re seeking to try and get ahead of problems.
We’re trying to understand our populations ahead of them getting ill or anticipating that we know that they’re going to develop more problems if we don’t work in a different way and that style that Tom’s talked about is very much about stopping it feeling like a transaction, which people feel as a patient and a person, as much as they do professionally, working in a system that is no longer about forms.
It might not even be phone calls. It’s more about conversations. Good old-fashioned conversations in corridors and meetings and professional discussions that mean it feels like continuity is better and that from a patient perspective we’re hearing the same story coming from our professionals in a neighbourhood as much as we would like.
Sarah Monks
Thank you. Emma?
Emma Kergon
Yeah, I think I just would like to expand on what Helen has just said, that that I think that some of the services that we’ve started that are anticipatory in Bradford, I think we’ve been very mindful that criteria’s got to be inclusive rather than exclusive to make it easier for patients trying to access services and I think it’s important that as we’re designing our services and building them that we do that in partnership with our communities.
It’s not what we perceive that the needs of the community are, it’s what they believe there needs to be as well. It’s not being done to them, it’s being done with them. It’s a partnership working, so I think that’s a key factor as well.
Sarah Monks
Jackie?
Jackie Wilkinson
For me, thinking about kind of neighbourhood team is definitely seamless care, which has been discussed by other people, but also looking and supporting as well as medical problems, non-medical problems.
I think we all have seen patients that that perhaps don’t need a GP appointment. They’ve come in with non-medical problems that could perhaps be supported in another way, and looking proactively at non-medical problems for me, is the future, absolutely.
And also working very much with previously siloed teams. You know the voluntary and the social sector bringing everyone together to make those communications seamless between the patients is very much important.
Sarah Monks
And Jackie it’s interesting you raise the point around non-medical problems in terms of GP presentations, reading the neighbourhood guidelines, they speak around issues such as homelessness and debt and anxiety around that. Do you think there’s a strong enough association between social problems and the consequences and results in the medical implications of that? Because I found that quite an interesting read the disassociation of both of those things. I don’t know what – I value your thoughts on that, if that’s OK.
Jackie Wilkinson
Yeah, I mean, we all know one thing affects another thing. So if we’re talking about homelessness, it’s going to affect washing, nutrition, access to medication, even access to GP surgeries. So we certainly can’t look at these in isolation, but it’s how we come together to support that. It’s not, you know, it’s not one person’s role, it’s not a GP’s role It’s not a social prescriber’s, it’s coming together, which is not an easy ask really.
Sarah Monks
Absolutely. Thank you. Emma:
Emma Kergon
I think Jackie is absolutely right. I think we’ve got to think less siloed working. I think the only way that we can move things forward is to be integrated and do multidisciplinary working. We can’t think that one discipline can answer all the issues for a patient. It’s got to be an MDT approach, it’s got to be holistic and it’s best if we can do one assessment that everybody contributes to really.
Sarah Monks
Wonderful. Just thinking about some of the comments that that you’ve made and part of this discussion around exactly what neighbourhood health could mean to us, and Nat you talked about the prevention and focus on population health, and Tom specified around the importance of pathways and doing the right thing. And Helena, about the approach and it being about a specific way of working, which Emma and Jackie also spoke about this non-siloed working and the importance of the perception and the voice of the community.
I’m really grasping that understanding of non-medical problems. I think it would be interesting if we now considered the role of primary care in supporting the implementation of the neighbourhood health guidelines, so we can think about in terms of integrated ways of working, what the outcomes might be for people and how that changes our approach. But what is the role of primary care, what do we feel primary care should be doing to support the implementation of those neighbourhood health guidelines? Can I come to you, Helena?
Helena Ebbs
I think it’s really broad, Sarah. So you know, on a really simple and everyday level, our primary care organisations are interfacing with the problems and challenges in each neighbourhood and can really advocate for what those challenges are, and they experience the difficulties.
So there are, you know, people working in primary care are able to describe the challenges and the problems really, really well. So we need their voice in the system, particularly in neighbourhood health partnerships, describing what the priorities are, what they’re seeing, what they’re feeling and advocating for their population.
But there’s something else I think that is key, which is less about advocacy, but more about leading and designing and innovating with partners. And I think without primary care there you cannot create the solutions that are needed, Tom’s already talked about that ability to pick up a patient with a problem and to know who to talk to and our primary care organisations are really key. They’re, you know, they are the core of neighbourhood working in most senses. We need them to also be guiding and steering what the solutions are, so they have to be at the table describing the problem. But they also have to be at the table helping us design what the answers are to those problems.
Sarah Monks
Absolutely. Can I bring you in, Nat?
Natalie Martin
Yeah. So I agree with what Helen is saying. I think that general practice is core to an integrated neighbourhood team approach and neighbourhood care. And I think that’s for a number of reasons. So primary care has great oversight of its population, especially now through total digital triage you often get in a group of partners, basically seeing what’s going on for their whole population across a week across 365 days a year.
And I think that the qualitative information that that provides has proved critical and that’s proved critical in my personal experience of INT and where a lot of our ideas and projects have come from. I think also you need that buy in – the INT can’t exist without primary care. I think it’s really at its core and you need primary care to buy in and in order for primary care to buy in, it has to be part of suggesting ideas about what’s going on. And also about that developing of the solutions because it has to feel that the solution is pragmatic and is going to work for itself and the population is serving.
Sarah Monks
Absolutely. Thank you, Nat; Tom?
Tom Holdsworth
Thanks. Just a thought about sort of creating integrated neighbourhood teams. Neighbourhood working is quite an interesting challenge in that the space that you’re trying to create is almost organisationally agnostic so you know, if one sort of aspect of the system becomes overbearing or has too much control on things, then actually it works less well.
So primary care will be absolutely key and vital for all the reasons people have explained.
I think there is this interesting challenge about how do you make an INT almost feel organisationally agnostic and I wonder whether in different parts of the country in different systems it will be different parts that sort of lead the convening. But the challenge will be not to let one part of the system sort of dominate or be overbearing, just at the last point, I think.
It’s maybe interesting to think about the data as well, and who holds the kind of health-related data around people that support you with population health-driven approaches and often really is primary care that hold that data which will be a really important part in working out which parts of your population you’re going to look at. If you’re thinking about risk scoring and risk stratification probably is primary care that hold the key details with that.
Sarah Monks
Thanks Tom. Jackie:
Jackie Wilkinson
I absolutely agree with what you were saying Tom. I’ve come in from the hospital to work very closely with the PCN. So if we can encourage that kind of working as well, I think that will improve the way that the INTs work as well because it’s not just GPs, it’s not just a PCN, it’s coming together. So those kind of more blurred boundaries or blurred working types will definitely be able to improve the INT working.
Sarah Monks
Thank you, Jackie. And I suppose we can often have, as Tom was alluding to, around the data that’s used, the information that we have around our neighbourhoods and population health. I’m going to ask a question, just for consideration is, do you think that GPs are aware of all aspects of the neighbourhoods and the needs of the neighbourhoods?
I’m just trying to think about the needs of unmet communities and the silence. People who don’t attend GP services, people who may often attend third sector organisations in place of that and how we are sure to include them in the considerations around neighbourhood health. Helena?
Helena Ebbs
Yeah. So I’m. I’m really lucky I get to work with lots of different PCNs in my role and different neighbourhood models. I suppose the first thing I would say is that GPs in particular have a very good grasp of what some of the problems are, and the majority of problems they will be able to articulate them really, really well. But you’re absolutely right that some things are hidden, and so if I give a couple of different examples.
In Selby, some of the work they’ve done there in North Yorkshire, they have worked with the schools and just by having a really good conversation with the schools, understanding school refusal and special educational needs and the huge impact of things like a lack of dentistry services and so on for children with deprivation and various other challenges. That was not well known and understood in the same way by primary care. Those children, yes, are being seen, but that particular need and element of their need was not well understood until those conversations were had.
And there are other examples I could give – some work on health inequalities in the City of York where people have looked at their data and actually their data has really exposed that people living in Core10 and core20 populations with much higher levels of deprivation were not getting anywhere near the same level of long term condition management. Not because they weren’t being offered it, but because they weren’t attending.
Now the problem with relying on your instincts and your experience as a GP is – it’s based on the people that you see and that’s why what Tom’s saying about data is really important. Being able to understand the people that you’re not seeing and what the makeup of those people is, that’s really crucial. So, so absolutely.
Your knowledge and experience matters, but you need to also have this sense check of the other people in your neighbourhood are experiencing what they’re seeing because that can really change and influence what your priorities are. Which is, I suppose, the final thing, which is to say again what Tom said. It’s not all about GPs, they’re really, really crucial in this mix, but it has to be all organisations within a neighbourhood contributing, otherwise you don’t get the right priorities overall.
Sarah Monks
Wonderful. Thank you. Some really important points there, Helena. Can I ask you to come in, Emma on that point?
Emma Kergon
Yeah. I just want to pick up on a couple of things. Thinking about developing new services and how well we work with other organisations, we’ve done really well with the proactive care team in Bradford and we work in real close partnership with our acute trust partners because we’ve done it from the beginning. So developing a service from the very beginning, really helps to have good partnership working.
And the other thing is as part of the proactive care team, we look at the demographic data, the risk stratification tools, to look at what patients are attending at practices or not attending.
So as much as you were looking heavy users of GP practices and time, we’re also looking at those that may have long-term conditions, frailty, but not have attended in a long time into practices and it’s with those patients that we have some of our greatest successes, so really kind of working hard to look at both frequent users who, as we’ve said, might not actually attend for health reasons, they need other support from different ways, but don’t quite know how to access it and see GPs as an entry point to that, but also being those patients who just don’t attend for other reasons and we need to work really hard to access those patients. And do the preventative work that we can anticipate that we can reduce problems further down the line for them.
Sarah Monks
Absolutely. As you’ll know yourself, just because we make a resource available, doesn’t necessarily mean it’s accessible in the same way.
Can I come to you, Jackie, please?
Jackie Wilkinson
Yeah, just agreeing with what Helena has said, us working in the Lower Valley with our community anchors has been absolutely amazing. What they brought to the strategic part of the INT as well as the MDT that we have running as well. Yeah, they’re on the on the forefront, aren’t they, of seeing these patients’ focus for hope in the space, have just been excellent bringing that point of view.
Sarah Monks
And just along the discussion of us speaking about the silence and invisibility of some of our community members. I wonder with the change in shape and nature of integrated neighbourhood working. what your thoughts may be on the importance of having a workforce that reflects the local neighbourhood and community? Can I come to you please, Emma?
Emma Kergon
Yeah. When we first started up our proactive care team, we had perceptions of what we thought the services might need- might be needed, and we were originally funded by RIC -, so reducing inequalities in communities money before it became mainstream and it gave us a great amount of freedom that we could start off and look to see what services we need, but over time have the freedom to change them.
So we’ve brought in roles such as mental health practitioners into the team now, we have pharmacy technicians in the team, so we’ve changed some of the skill mix around our therapy, but you need to have freedom within your services to be able to flex. So as you can see changes within demands and communities, your services can be reactive to what demands are coming through.
So it’s been a joy to be in a service where we could flex. And I think that’s important when we think about designing services for the future that to be able to flex, to reflect what demands are.
Sarah Monks
And what you’re talking about there as well, it raises the importance of really understanding your local neighbourhood and community need, given that the resources are going to be solely focused on what comes from the data and that local knowledge. Can I come to you, Helena?
Helena Ebbs
Yeah, absolutely. So there’s a couple of things you talked about, you know, the roles that we need in integrated neighbourhood working. So I think you know most of us who’ve been focusing on this for a bit would have to advocate for the non-clinical roles that provide enormous value in integrated neighbourhood working.
So whether that’s care co-ordination or social prescribing, health and well-being coaching – there’s some models from around the country and we’ve adopted it in some areas of North Yorkshire around community health and well-being workers. And I think the power of those people is that well, first of all, they’re highly acceptable to the people who need them.
So people really enjoy and value those roles, and that’s the lesson for all of us, I think, to recognise, but also they have an ability to bridge services in a way that is far better than some of the traditional clinical roles, for example. And they have the ability to be more flexible in this sorts of offerings that they give.
So it’s really holistic, it’s really meeting the needs of the people that you know, particularly with complex needs. In the case of community health and well-being workers, what’s so powerful about the way that model works is that those people are from the communities in which they serve and that’s really important – integral to that project.
And that is so important for both understanding people’s challenges, but also for trust and in areas of really high need populations who have particularly experienced challenges and services over the years. People with very high levels of deprivation, trust is really, really key and having people from those communities working with those communities and bridging services and gaps is so helpful. I have been amazed by the results, but also just the case studies and the professional changes that have been made as a result of having those members of the team around.
Sarah Monks
Absolutely. Thank you, Tom?
Tom Holdsworth
Thanks. I just wanted to mention occupational therapy as a as a role that we found extremely useful in terms of developing integrated working, to a degree that I didn’t expect really when initially brought the role in, but the holistic skill set, the crossover between mental health and physical health – they’ve been really brilliant at doing some of this sort of integrated working locally.
So that was the first point really. I think there was a second point for me just about thinking around workforce development and thinking a lot of our workforce are not really trained to work in this way and we need to think about training a workforce for the future rather than a workforce for the past. So thinking our system’s getting their head round, what do you need to do locally to train and upskill your workforce in some more generalist ways of working, ways of working across organisations. So I think that’s a really interesting challenge.
And then the last bit really is something that is perhaps outside of our direct sphere of control, often in primary care, but something that comes up again and again. And it’s regarding contracting for voluntary sector organisations and how the system can contract in a sustainable way to put these organisations on a more secure footing, because often they’re really key part of our neighbourhood teams that have real problems in terms of short-term contracting and fragility really of those organisations.
Sarah Monks
Absolutely. Thank you, Tom. And that point around workforce development absolutely is key given as we mentioned at the beginning, the increasing complexity, caseload management in community, especially with the shift from hospital to community and changes certainly around Mental Health Act as well. Emma?
Emma Kergon
Yeah. I just wanted to say that I think one of the important roles that we’ve got in Bradford that we’ve just started are self-management facilitators. So that element of promoting self-care which takes a lot longer to do with patients. So we’ve got people who can spend much longer time with patients, teaching them, educating them, thinking about ways that they can do self-care, whether that be injecting their own medication, doing their own wound care.
But it’s going at that service user’s pace so that they are confident to take over that element of care, but it involves having a bit of a cultural shift in both for service users and for clinicians and practitioners to have a different kind of conversation. So it’s about shared decision making and I think that’s something that we need to do much more, I think right across services and think much more about how we can promote self-caring and have those discussions much earlier really.
Sarah Monks
Absolutely. I think that sharing in decision making is going to be key in that collaborative space, but also is going to be the confidence in clinical decision making and that safe – psychological safety that we can create in community to support more innovative and positive risk-taking approaches to supporting our communities and neighbourhoods, enabling people to receive care at home rather than shifting care towards hospitals. Nat, would you like to come in?
Natalie Martin
Yeah. So I think I just wanted to comment on over the course of our INT over the past two years. I think it’s become increasingly apparent how much of a role there is for the voluntary sector and especially the food bank. So we’ve done a lot of work with our local food bank and they’ve been kind of essential as an ’in’ into patients’ lives and the same with the voluntary sector.
So often these patients that are not represented in primary care that aren’t presenting are presenting to them or are known to them and having their input and that trusting relationship that they’ve developed allows them to feed into what we’re doing as an integrated neighbourhood team and to help them. I think us supporting the food bank, so finding out what it is that they need and what it is that they struggle with and it’s been a bit of a mutual support thing.
And things like putting the children’s social prescriber in the food bank, which is an initiative that we’ve done, has been really successful and just that the idea that yes, the onus should need to be across the whole team and think with our latest project which is around neurodiversity in under eights we’ve seen the having a really diverse mix of partners – so we’ve had Healthwatch doing some projects and getting stories from parents, we’ve had a heavy school involvement, council involvement, food bank involvement.
Just that everyone having a voice around the table and leading the direction of that project has been brilliant.
Sarah Monks
That sounds wonderful and so impactful. I’m sure there’s a great amount of satisfaction that’s gained from that and make some real changes to people’s lives.
I wonder in this group about any other initiatives that you’d like to highlight in this podcast that people might be able to make contact with you about, or maybe an innovative ways of working feel are important to raise here. Can I come to you, Helena?
Helena Ebbs
Yeah. So I mean that example is the perfect description of how integrated working is making headway and there are lots of different examples – Bridlington’s doing some brilliant stuff around learning disabilities and integrating a health and social care approach to annual health checks using this non clinical care coordinator roles. Selby is doing the community health and wellbeing worker work that I’ve already mentioned. And there’s proactive social prescribing happening aplenty across Humber and North Yorkshire.
So this kind of theme around bringing – moving – our staff to work in the place where the need is and working collaboratively around what the priorities are is gathering a huge amount of momentum. I think what’s really exciting and I can – you know, I want to talk for hours with everyone on this call now about the work that they’re doing – is that this this way of working is incredibly professionally rewarding. And those people who have been leading this work are getting so much positive feedback from seeing the results that this delivers that tells me that there’s momentum in this that will carry us forward because it is the right thing to do. There’s some exciting things ahead, I think from this work.
Sarah Monks
Absolutely. I’m just sat here smiling as I’m listening to everybody’s case studies around the amazing work that’s happening. Can I come to you, Jackie?
Jackie Wilkinson
Yeah, in the Lower Valley, and it’s similar to what Tom was saying, me and Michelle Agus, who is our Lower Valley OT got together to create an INT MDT – so, a multidisciplinary team – meeting. We really wanted to focus on improving communication, Improve appropriate referrals whilst lessening inappropriate referrals as well. And we just invited everybody that we could think of to come to these weekly MDT meetings.
So it’s supported by social services, the mental health team, the voluntary sector, the hospice services as well as GP involvement, social prescribers as well and like what Helena was saying, the feedback has been so positive from the people that attend this INT MDT because they feel very much supported and I think it was mentioned, possibly by Tom, I can’t remember.
We don’t have all the answers and that’s quite – as an individual, professional or person and to come together to discuss it with other people, the ideas and the improvement of services for our patients has just been absolutely excellent. But definitely yeah, the support for the people who attend the meeting has been really appreciated as well and we’ve got some really good case studies that we’ve had. The INTs been running since December last year and it’s just a great way to incorporate the neighbourhood thinking, you know, the approach to things.
Sarah Monks
Thank you, Jackie. And we can never underestimate the amount of people we need to really do some effective problem solving, which is often something we don’t speak about.
But it’s absolutely essential in community and neighbourhood working I’m going to come to you, Nat.
Natalie Martin
Yeah. So I think one another sector to think about that we’ve had some success with is the the care homes. So actually we noticed that the care homes were struggling quite a lot.
They struggle with staff turnover. They’re often contacting us when they perhaps don’t need to, and we took this on as a project and what we’ve been doing is working with the care homes- we held workshops for care home staff. They came along, fed back what difficulties they were having. What things were working well for them and how we could help?
And then we established some key themes that were particularly problematic for them and work together with different partners across the primary care team to design a training programme for them that we put in place. And through delivering that which is an ongoing thing that we want to keep going throughout the year, partly due to the staff turnover issue, we have seen them grow in confidence, them reporting back and feeding back to us that they feel better able care for the residents, that the number of contacts to primary care and to the district nursing team has decreased and the quality of things like skin tears have really improved.
So that’s been felt to be a really positive project and it’s also really improved kind of relationships between all those different community providers.
Sarah Monks
Well, that’s an incredibly powerful positive example there Nat. Thank you for that. I’m going to come over to you, Emma.
Emma Kergon
Yes, thank you. The initiative that we’ve been seeing really good success with is the proactive care team that we’ve got in Bradford. It’s in a central locality, so it supports 3 PCNs in really high levels of deprivation and health inequalities. So we’ve got 12 disciplines.
So a really large MDT source to pull from and the aim of the service is to address patients with immediate and short-term needs, to help them live well, avoid unnecessary GP appointments or unplanned admissions.
And we do that by proactively looking at risk stratification tools, look at our A&E attenders doing engagement events. outreach work and then also accepting referrals in from all colleagues and patients and carers. And like I mentioned earlier, we go for an inclusive rather than exclusive criteria. So we do that and look using MDT approach, holistic assessments, we do the blurred boundary working.
So we’ve got areas of commonality and we’ve pulled and learnt from one another as well.
And that we’ve had enormous success from working in this manner and we’ve seen a 41% reduction in A&E attendances and a 31% reduction in unplanned admission.
So we’re really thrilled with the service. It’s done so well now that we’re just about to start our second pack team in the Keighley area, which has a similar demographic, maybe on a smaller scale, but we’re about to expand when we know that the benefits that we’re seeing that proactive way of working and anticipating people’s needs does seem to be really beneficial, really, and like Helena was saying, the benefits are also seen in staff we’ve got really high retention rates, staff surveys are good, low levels of sickness, everybody benefits from working in this manner. So we’re really thrilled with our results.
Sarah Monks
That’s incredible, by the way. Really powerful outcomes. Tom?
Tom Holdsworth
Thanks Sarah. So in Sheffield we undertook a piece of work in last autumn to try and take a sort of snapshot of what’s been happening in Sheffield around integrated working and that was really interesting sort of project, lots of work looking at risk scoring, frailty and proactive care, sort of things that people have described already.
The other 2 big areas that came out were chronic pain. So really interesting area for integrated working where you can get into using de-medicalised approaches, peer support and we often don’t have very good, medicalised interventions for it.
So lots of people doing interesting work around chronic pain and then also diabetes and metabolic health was the other area know this huge, huge problem with sort of increasing rates of type 2 diabetes and again really lends itself to sort of community-based working and integrated neighbourhood teams.
And I suppose the last thing I was going to say is just in terms of the 10 year plan and what might hope, I guess, I’m really hoping that the 10 year plan supports some of this organic work that has grown up and you know really if top-down sort of strategy and direction could meet that bottom-up organic growth and that would be fantastic for me to sort of be able to drive this on really to the next level.
Sarah Monks
Wonderful. Thank you, Tom. Jackie?
Jackie Wilkinson
I should talk about my role really. We talked a lot about proactive and that’s exactly why the aging well role was set up. So we use the GP computer systems to pull data so it can be from one example from somebody who’s frequently attending GP surgeries to actually ghost patients, patients that don’t tend to attend as much and proactively call these patients up and offer them a service and looking at something holistically.
So home improvements, grab rails, osteoporosis risk, hoping to reduce the risk of falls and hip fractures in the future, promoting strength and balance in exercises, dietary advice – that’s the work that’s going on in Calderdale with the aging well team.
Sarah Monks
Absolutely incredible. Thank you, Jackie. So I was just looking over some of the comments that we’ve had during this discussion and please correct me anybody if I’m wrong, but when we think about what we’d like to see in the next 10 years, in the 10 year plan, just looking at some of the themes that have come out through our discussion that you said at the beginning about the real opportunity for look at preventative measures and then that real in-reach stuff specifically within care homes as well where you’re able to be more proactive.
I’m really engage with people, maybe perhaps in a different way than has happened before. I think as we look for the 10 year plan coming out, I will assume that. If we just go around the team, if that’s OK and just in two words which areas of focus would you like to see prevalent when the 10 year plan is published? What for you are the most important areas that you would like to see in the 10 year plan? Can I put you on the spot, Nat, and start with you?
Natalie Martin
I’m afraid I’d like to see them all, so I want to see a switch to preventative medicine. I’d like to see a movement from a hospital- secondary care to community. And I would like to see a switch from analogue to digital because I think you need all three of them, in order to deliver what we need, and I hope that we see the funding flowing in a way that allows it to do so.
Sarah Monks
Thank you, Jackie?
Jackie Wilkinson
I think for me, just a seamless communication absolutely working with, you know, between us all services and knowing what the other person’s doing is the most important aspect for me and I hope that’s mentioned in the plan.
Sarah Monks
Thank you, Helena?
Helena Ebbs
I think if we’re going to move to that proactive way of working, we need to have really good integrated neighbourhood partnerships that have got sight of good data, that they can start to prioritise what they do and make the changes.
Sarah Monks
Wonderful. Thank you, Emma.
Emma Kergon
I think everybody else has covered it nicely – absolutely. All the three things that we’ve discussed, hospitals, community sickness, to prevention, digital and analogue.
All that and anticipatory care, but also Jackie’s covered it nicely about seamless working. It’s got to be easier to link in with other organisations and have digital and support mechanisms that that enable us instead of creating barriers.
Sarah Monks
That makes complete sense, Tom?
Tom Holdsworth
I’d like to see the system really sort of pivot its line of sight and focus to communities and neighbourhoods. I think that’s the most important thing is where the system puts its focus, its energy and its attention.
Sarah Monks
That’s wonderful, thank you. And I suppose for myself, I’d like integrated neighbourhood teams and neighbourhood working to be built on the foundations of the voices of people in the community and neighbourhoods – not just the voices that are often heard, but including silenced hard to reach voices in our communities and to evaluate effectively, which is something that I think could sometimes be lacking.
So thank you all for joining, our discussions were really interesting. I think I’m certainly in the sense that I got is just a real passion for person-centred, collaborative, proactive partnership working that creates such an impactful and measurable outcome for people who really need that the most, and the fact that everybody’s got a different perspective and angle on it just shows you all of the opportunities that are out there.
That integrated neighbourhood teams and how we imagine them and how we report on them and share them, can really change the way that we’re working and also place value on different types of roles and different assets within the community that we can use.
So I want to thank you all for being part of this. I’m sure this is the first of many conversations around integrated neighbourhood teams and it’s been a real pleasure to speak to you also. Thank you.