STP undertakes various interventions to build a carer friendly system with less bureaucratic interferences, reducing risk of depression and isolation amongst stigmatised carers

Synopsis:

Carers face real health inequalities, make up 10% of the population but are too often seen as an add-on. STPs present threat and opportunity: savings and additional process, but a real chance to drive consistency. This STP is attempting (without additional bureaucracy) to steer the public sector tanker towards a more carer-friendly way of doing all its business.

This is evolution, not revolution: Hertfordshire’s multi-agency carers’ strategy began in 1995. Partnerships have broadened and deepened and are now developing and sharing vision and practice across the footprint. Carers’ champions have spread across the system, producing evidenced outcomes often at little cost. Vision and evidence-base have been honed and solutions designed (and redesigned) with carers (15% of CinH contract is spent on engagement).

The partnership is now working to pull together evidenced best practice and innovation and has four agreed priorities for the footprint; Hertfordshire has a new five stage pathway; and across the footprint social prescribing and community support is being better integrated. The award is not sought for the current end state, but for sustained vision and endeavour across the STP which is pragmatic and driven by carers themselves. Delivering now, but with much more to deliver in the future.

Challenges/Goals:

The challenge: creating shared carer-friendly culture. Carers need to trust ‘the system’- so do busy GPs, nurses, housing officers. Why reach out if you don’t know there are skills, time, networks to support you? Carers like professionals fear taking lids off ‘cans of worms.’ So a systemic approach needs as its key goal: more carers identified earlier with better outcomes.

Seventy per cent care < 20 hours (2011 census). Targeting them prevents ill-health and sustains carer (and person’s) wellbeing. We’re changing default settings from statutory first to community first wherever appropriate (less stigmatising and bureaucratic), ensuring all needing formal support get it. Progress towards ‘no wrong door’ is evidenced by steady reductions in years caring prior to referral to CinH.

Non-stigmatising carers’ passports, champions in primary care, libraries, fire service; social prescribing (In Herts (Hertshelp, linked to community navigators, Hertswise, carers’ champions) in West Essex (Care Navigation Service, Frontline (on-line tool to support self-care) and Care Navigators) increase access to identification and support (even if the carer label is shunned). On-line registration can take the strain, registering carers with ACS, CinH and GP simultaneously. The Dacorum pilot, investing time (not money) in enhancing local networks, will enhance outcomes in localities.

Outcome:

• Primary care (HVCCG): 67 champions - increasing carers registered to 9,626 (March 2017) - up 36% in three years; carers’ health-checks: 2,023 (up 40% in 3 years); 5,900 carer flu jabs, up 32% in three years).

NHS Trusts: HPFT (MH Trust): (commissioned HCC/ENHCCG/HVCCG): 19% increase in new carers identified 2017-18; 230 referrals to CinH since 2015. Herts Hospital Trusts: Carers Lead nurse now permanent; WHHT (made 81 referrals to CinH April-December 2017); ENHT carers nurse RCNi Commitment to Carers Award 2017. Herts Community. NHS Trust: 52 carers’ leads across Herts identifying 700 carers pa, 97 direct referrals to CinH 2017/18

Early identification (CinH): Carers’ registered with CinH now 28,145. Years caring before registering down from 12 years (5 years ago) to 5.08 years for those registering this financial year. Supported by 11,629 carers’ passports issued (discounts with local businesses). Carers’ separate assessments: Herts ACS example: 2012/13: 974; 2016/17: 4,343 (289% increase). HCC funding for support more than doubled 2014-2017. Access to informal breaks: Helping you care (Crossroads) direct access breaks at home (up to 18 hours) as gateway to longer term arrangements (private/via carers assessment). Carers per quarter 1070 (2015-16) up to 1600 (17-18). CinH provided 1,148 carer learning places.

Spread:

• STP/NHSE event April 2018 – sharing HVCCG/ENHCCG learning re identification in primary care, national ‘quality markers’ (CQC-endorsed) encouraging GP take-up and influencing work under new Carers First contract (Essex)

• Carers Passport nationally influenced by Herts developments • Recognising carers online tool allows HCT/WHHT to refer electronically

• Lister Carers Lead Nurse pilot funded first by HCC, then by CCGs, and adopted now by Trusts

• Social prescribing partnership including CinH, builds into county service. HVCCG officer ‘carers lead’ for national SP steering group

• Care Navigation Partnership: Age UK Essex, Smartlife, Community Agents, Provide’s Lifestyle Service) jointly commissioned (WECCG, Public Health, ECC)

• SF12 prevention of depression/economic impact of MADFC evidence shared by HCCPH/ACS/HVCCG with NHSE,via State of Caring conference, poster to first international SP research conference (14 June, Salford Uni), with Surrey STPs and Carers UK

• Carers Exemplar STP (NHSE)

• CinH Peer Mentoring Service written up and evidence shared

• ADASS regional carers conference – presentation on STP work spring 2018

• Presentations in Canada and Sweden and nationally on carers and social prescribing

• Role of HertsHelp as hub in Herts: supporting integration of voluntary sector response, social prescribing, the Hertswise model (dementia) integrated hierarchy of support for people and their carers (including Admiral Nursing support)

Value:

Quality Metric SF12 before and after surveys of carers receiving low level help (average < £300) via Make A Difference for Carers (CinH/primary care): 24% reduction in risk of depression (nett saving £255 per carer)

• Using Baker Tilly (2011) as proxy for carer centre work:ROI of £13.60 for each £1 invested. Much of value associated with early intervention, first year yielding 60% - or £8,567 – of lifetime impact

• 54% of young carers contacting CinH reduced their responsibilities: 46% had improved outcomes

• CinH peer mentoring, caring with confidence led to (carers self-report): 92% less isolated; 90% more positive/less stressed; 85% accessed a break

• First ever GP led carers’ survey 2016 (HVCCG): 891 carers responded; awareness and take up of winter flu jab: 80%; 76% aware of carer health-check service; 63% took up offer. Self-reported health issues: musculoskeletal 53%; stress 41%; depression 35%, insomnia 34%. Carers appreciate efforts made: ‘a first rate service - particularly the flexible appointments as it is often so difficult to find time to get to the doctor’s in between caring and working.’’

• 20% of GPs (survey) said this reduces practice workload; 50% said social prescribing did

• Carer peer mentoring increased confidence and access at minimal cost

Involvement:

• The HWE STP

• Carers (through many forums, but particularly Herts Planning and Partnerships Group and carers’ reference group)

• Young Carers (through young carers council, regular ‘speakeasies’)

• HCC (ACS and CS), ECC

• NHS Commissioners: HVCCG, ENHCCG(joint commissioning £1.2m to CinH with above), WECCG

• NHS and social care Providers (carers’ policies in contracts)

• Carers’ Organisations across footprint

• Other voluntaries

• PH in Essex and Herts (Carers JSNA)

• Libraries Services

• District Councils

• Community Pharmacy

• NHSE and other NHSE Carer Exemplars (Surrey, Greater Manchester, W Yorks)

• Private businesses (discounts through Carers Passport)

• Employers for Carers/Carers UK

• Herts Money Advice Unit

• Fire and Rescue (Safe and Well)

• HertsHelp and Smart Life and social prescribing networks in Herts and West Essex etc

• National Social Prescribing NetworkThe new pathway will clarify key roles and local action with relevant commitments for all agencies.

The key is taking the model to all localities across the footprint (planned over 12 months) building stakeholder commitment to the vision, the network and each other. We know 55% of GPs (W Herts) would identify less carers without champions/support. If I understand my role and boundaries I can afford to identify you have an issue, knowing I won’t have to deal with it alone.