Organisation introduces care partnership to streamline services for patients and reduce handoffs, improving quality and safety outcomes for older people in care homes

Synopsis:

The Gateshead Care Partnership (GCP) was formed in 2015 to streamline health and social care services for the residents of Gateshead. The members of the GCP include Gateshead Council, Gateshead Health NHS FT, Community Based Care, Gateshead GPs, NTW Mental Health Trust. The members committed to work together to streamline services for patients, reduce “handoffs” between services, work together to meet rising customer expectations, mitigate our joint financial challenges, bid together for contracts, manage increasing demand and complexity and share good practice.

The GCP was set up in the context of services being fragmented across and within organisations. Although most partners were rated “outstanding”, “excellent” or “good” we wanted to do better for residents and simplify their “journey”. We are determined to address our joint challenges of increasing demand and complexity, reducing resources and health inequalities described in our Director of Public Health’s Annual Report.

In particular we wanted to support our Council in mitigating their financial challenges and delivering their ambition that every person, family and community in Gateshead should “thrive”. Our activity has focused on two areas - bidding for a Community Services Contract as a platform for integration and transformation and building trust as the basis of a provider alliance.To date our outcomes, as described below, have been positive and delivered jointly between our Council and NHS providers. The GCP is now developing into a provider alliance to co-ordinate services and address challenges on a more formal basis.

Challenges/Goals:

The main challenges we set out to solve included - primary and community services being delivered in a fragmented way across Gateshead by the Council and four different NHS organisations - although relationships were good there was a lack of co-ordinated service planning and a forum to resolve service challenges and manage integration - financial reductions across health and social care of almost £40 million each year in Gateshead.

This was especially acute in our Council - increases in demand linked to demographic change and an ageing population of some 2% per year across the system for adult services. For Children’s Services initial alerts had increased by 11% - health inequalities including a 10 year difference in life expectancy within and between the wealthiest and most disadvantaged communities in Gateshead

- the need to sustain General Practice and reduce admissions to acute care especially from care homes

- the stabilisation of a volatile home care market to facilitate transfers of care

- a shared workforce challenge.

Our goals were expressed in our Transformation Principles which state we will -

prefer generalism to specialism

- integrate services in localities

- have shared ways of working with the Council

- right person, right place, right time - remove hand offs

- remove duplication - reduce financial outlay

- deliver high quality services

- show leadership at all levels across services

- use project management principles Our goals reflected these principles and included outcome measures agreed with the CCG particularly moving to locality working clustered around GP Practices and co-ordinating services.

Outcomes:

The GCP secured the Community Services Contract which mobilised in October 2016. We set up a Transformation Board with cross organisational representation and work streams with intensive frontline staff involvement.Since 2016 we have

- maintained patient satisfaction at above 90% and improved the quality and safety of services. For example we have significantly reduced falls in a Council facility, Eastwood, through joint working and co-location

- saved over £1.5 million

- created co-terminus localities between GPs, the Council and Community Services

- re-organised staff to work in localities based on GP Practices and created links between Council and NHS locality based services

- changed the working hours, job descriptions, locations and clinical practice of 250 NHS staff to enable them to work in an integrated way with GPs and social care

- with our Council shaped the home care market over Winter using “bridging” packages to sustain our good performance on transfers of care

- agreed a shared skills framework between GP Practice Nurses and Community Nurses

- shared our Nursing workforce at times of pressure

- shared our project management and transformation workforce to work jointly

- extended our shared care Home Vanguard to an extra 15 residential care homes and reducing admission to acute care

- introducing a shared IT system and patient record to 30 GP Practices and Community Services to improve decision making and referral processes and enabled shared viewing access to social care records

- implemented a trusted assessor model on the acute wards with our Council to facilitate discharge

- integrated Learning Disability Services into the GCP

- through integrated working across children’s services achieved a positive OFSTED SEND Inspection Report

- used the GCP as a forum to jointly plan services, resolve issues, understand joint challenges and enhance trust

- achieved positive outcomes in CCG Assurance Visits and an ADASS Peer Review in 2018. These outcomes were achieved through shared planning, implementation and evaluation by our Council and NHS partners.

Spread:

This is an area for improvement and we would hope to use the HSJ Awards to help us share our success more widely. So far we have with our CCG been invited to present to neighbouring CCGs about our work in Gateshead and the benefits of working in partnership. We have been active in our sub-regional Emergency Care Working Group in explaining our work.

Our GP colleagues have visited other nearby GP Federations to describe the advantages of the GCP and their experience. The Care Home Vanguard, which is part of the Community Services Contract, has been the subject of national evaluations and assessments by Northumbria University. We have shared our work at a number of local area networks such as the Regional Frailty Network.

One of our more important “spread” activities has been raising the profile, purpose, skill and offer of Community Services with acute sector colleagues through a managed communications activities. Most recently we are participating in newly formed national Community Services Networks. We are via ADASS sharing our experience and outcomes. We have met with other Councils in the region and been consulted by them on partnership working.

Value:

See section 6 above. In Community Services we have - maintained and enhanced clinical standards and delivered £700,000 quantifiable monetary efficiency savings in year 1 of operation

- maintained Family and Friends scores at over 90% satisfaction

- sustained our transfers of care performance

- extended patient choice by extending service hours from 9-5pm to 8-8pm

- reduced handoffs for patients in care homes

- reduced admissions to acute care from Vanguard Care Homes, increased the number of care home patients dying in their place of choice and improving care standards in care homes

- by sharing nursing resources offering services in GP extra care centres at weekends e.g. compression dressings

- co-ordinated care through multi-disciplinary team meetings with GPs and social care about complex patients in venues such as Eastwood

- improved outcomes for very frail older people in care homes by participation in “ward rounds” with GPs

Involvement:

Our Council and NHS partners have been fully involved in the GCP and in the Transformation Programme. This includes

- all Gateshead GP Practices, GPs, practice staff and managers in the formal GCP Meetings and 8 transformation work streams

- senior Council staff in the formal GCP Meetings, in 2 workshops and frontline staff in the 8 transformation work streams including shared leadership, approval of reports, monitoring progress and sharing patient and service user feedback

- the Councils Overview and Scrutiny Committee in presentations, advice and questioning

- the wider health and care sector through regular communication, attendance at GP events, presentations to the Trust’s Council of Governors and Board

- engagement with the voluntary sector through their active participation in the work streams.

For example FACT, a Gateshead based cancer charity is a critically important partner in our work on End of Life Care. Staff engagement in a period of change was vitally important. We harnessed the skills and experience of a group of 84 staff to analyse the current position, identify challenges and create solutions. External partners, especially the CCG, have been supportive and encouraging.

We have engaged with Acute Care Consultants in our Falls, end of Life and Frailty work streams gaining their support for systemic change. We have linked with patients, families and carers through the existing consultation and involvement groups especially those facilitated by the CCG. We regularly use patient feedback and our clinical reporting systems to measure and monitor quality and satisfaction.