Pennine Lancashire Integrated Care Partnership Annual Report 2018/2019
Introduction We know that people in Pennine Lancashire are more likely to experience ill health compared with people living in most other parts of the country. We have high levels of deprivation, poor health outcomes and greater demand for health and care services. The good news is that we can prevent many of our illnesses, and by working together, we can help improve people’s health and wellbeing whilst continuing to provide effective and efficient health and care services.
We are proud of the health and care services we have in Pennine Lancashire. Our doctors, nurses, care workers and wider health and care staff are doing all they can to provide high quality care for people who live and work in Pennine Lancashire.
Over the last year we have been working with residents, volunteers, doctors, nurses, health and care professionals, community workers and others to move forward with our plans for change. We have listened to what people have had to say and we have delivered on a number of proposals which are set out in this document. We are making our services the best they can be. Our doctors, nurses, pharmacies and other health care professionals are working together in our neighbourhoods , hospitals and urgent care services and are providing more support in communities. While we are delivering new and improved services and resources we also need everyone to look after their own health as much as they can, to make healthy choices in their lives, use services appropriately and support their families and friends to live healthy lives. Only by doing this will we all be able to continue to achieve the changes needed.
We believe if we all work together we can overcome the challenges we face. Everyone has a role in making Pennine Lancashire a healthier place.
Graham Burgess Chair: Pennine Lancashire Integrated Health and Care Partnership
There are a number of health and wellbeing challenges in Pennine Lancashire: • More people are likely to experience ill health here than anywhere else in the UK • Higher levels of deprivation • Poorer health outcomes • Bigger demand for health and social care services
Together A Healthier Future represents all the health and care organisations in Pennine Lancashire, along with local councils and voluntary, community and faith sector services.
In 2018/19 we said we would…
Deliver safe, effective and high quality care by transforming services: Urgent & Emergency Care - Delivery of our A&E performance trajectory Mental Health – delivery of our national and STP level performance requirements Delivery of our Delayed Transfers of Care performance requirements
Deliver a system financial control total: •
Enabling the system to work on items such as Finance and Population Health Management
Improve population health and wellbeing by focusing on delivering: • Neighbourhood Health and Wellbeing Teams
Delivery of our required Referral To Treatment performance
Prevention at Scale and Together an Active Future
Strengthened general practice Improved mental health and cancer services
Frailty and End of Life
So far this year…
• Made good progress with a focus on delivering strong services, with good patient experience, whilst maintaining sound finances • Delivered a set of specific improvements on care pathways • Agreed ambition, commitment by our leadership population and strong strategies that set out ways of transforming health and care services and deliver tangible improvements in Pennine Lancashire • But we have a long way to go and tough decisions on managing finances and demand are ahead
Our vision: “For all of us in Pennine Lancashire to live a long and healthy life. Any extra help and support we need, will be easy to find, high quality and shaped around our individual needs.”
Prevention and Social Prescribing
We aim to achieve a step change in mobilisation of front line staff for primary and secondary prevention, by increasing social prescribing (connecting patients to community services to help in their healthcare) and other non-clinical interventions, in order to improve peoples’ health outcomes and reduce demand on clinical services.
In 2018/19 we… 16
Secured the support of 16 out of 24 GP practices in Blackburn with Darwen (BwD) to take part in the Prevention at Scale programme that encourages people to attend health checks and make positive changes
of Wellbeing Service clients who have achieved all of their wellbeing plan goals have maintained that positive behaviour six months on
In Focus: Tea Time Club, Burnley: GW, a single parent of three young children from Burnley was experiencing social isolation and financial issues due to his situation. Through the Small Grants Community Funding projects he was introduced to the Tea Time Club at St Mark’s Church who supports parents who are struggling to cope. Despite often being the only dad, GW and his children were made to feel welcome and have now become regulars. Fellow members have noticed a positive change in the family with GW becoming a ‘hands on’ dad. GW feels more confident now that he has the support of the group.
Neighbourhoods and Community Health Services Neighbourhood teams made up of frontline professionals (GPs, community nurses, therapists, social workers and Voluntary Community Faith and Social (VCFS) partners) work in partnership to improve and integrate the care provided to 13 local Neighbourhoods of 30- 50,000 residents across Pennine Lancashire.
In 2018/19 we…
4 Neighbourhoods within BwD were
364 Days a year availability of the GP extended access scheme that has improved services with evening and weekend appointments
established with Neighbourhood Teams, allowing for a single point of access for assessments and referrals
In Focus: Cervical Screening in Neighbourhoods: Cervical cancer screening rates in Blackburn with Darwen ‘North Blackburn Primary Care Neighbourhood’ have increased at all six between October 2018 and May 2019. Thanks to work with community groups including the Awaaz Women’s Group to help support more BME women to attend cancer screening appointments and through the delivery of awareness training to newly recruited cancer champions. Local councillors have helped to spread key messages in their constituencies as well.
We are transforming Intermediate Services to help people stay out of hospital (step up) or support people at home after a hospital stay (step down) by providing
In 2018/19 we…
58 Care/nursing homes are working with Discharge to Assess (D2A), assessing people in a setting outside of the hospital that is more suited to their needs, to achieve approximately 10 discharges/week
3161 people were discharged and received all of the support they needed to complete their recovery at home
In Focus: Home First: Andrea was badly injured in a road traffic accident. After spending three months in the hospital, she wasn’t confident in her ability to cope at home on her own. She was referred to the Home First team who provided a home assessment and mobility aids including a ramp and commode. Support workers were also assigned to visit Andrea twice a day. “I wouldn’t have been able to come home without the help of the Home First team,” said Andrea
We are supporting the Regulated Care Sector to provide high quality and safe services, and to be a fully integrated part of the neighbourhood teams in Pennine Lancashire. Through the Enhanced Health in Care Homes framework and expansion of the programme to include Home Care and Supported Living, wee are working on stabilising and strengthening the care sector.
In 2018/19 we…
82% of East Lancashire and 77% of BwD care homes, with support from ELHT are utilising the Red Bag Hospital Transfer Scheme,
18.2% increase in the number of residents treated “on scene” by North West Ambulance Service therefore avoiding admittance to hospital
where patients are provided with all essential items needed when sent to hospital.
In Focus: Playlist for Life: After attending the Playlist for Life training in June 2018 the Longfield care home worked with a resident, Mary, who was very agitated and aggressive due to her dementia and refused to take part in activities of daily living such as getting dressed, eating and drinking. They worked with Mary’s family to incorporate a music playlist into Mary’s care plan and played her favourite song just before and during her morning routine which has made a hugely positive impact.
Urgent and Emergency Care
We are working to improve our Urgent and Emergency Care services so that people in Pennine Lancashire get the right care in the right place, when they need it.
In 2018/19 we…
5 New units and services: the Ambulatory Emergency Care unit , Older Person’s Rapid Assessment unit , Surgical Emergency Ambulatory Care Unit and the Respiratory Assessment unit , the Home Non-Invasion Ventilation service, new strategies/processes implemented and capital investment secured (Acute)
7 Day Falls Response Service embedded in Pennine Lancashire providing occupational therapists placed within multi-disciplinary rapid response, acute and emergency care teams 7- days a week to help with patient falls and prevent longer hospital stays
In Focus: Some of the differences made:
We’ve Reduced the average length of time people stay in hospital by supporting them to get home or be transferred to a more appropriate setting sooner. Patients are experiencing faster transfers from the ambulance to the emergency department. We are seeing an improved Ambulance Response Programme .
We are working closely with the Lancashire and South Cumbria Integrated Care system to deliver the ambition of the Lancashire and South Cumbria Digital Plan which aims to use digital technology to Empower the Person; Support the Front Line; Create the Future; Manage the System Effectively and Integrate Services across Pennine Lancashire.
In 2018/19 we…
11 local high schools in Lancashire and South Cumbria, involved in the “ Digital Healthy
25 Thousand pounds of funding was secured to develop a digital health hub in Blackburn Library, to help promote digital inclusion and digital health service support
Schools ” programme – teaching students about the risks of the unregulated digital health space and the safe Apps available for physical and emotional health and well-being
In Focus: Connected Healthy Communities: A partnership project designed to help monitor the safety of vulnerable adults by using low cost passive sensors has been rolled out to 45 local homes. The sensors, send back data to assess if the resident is moving around okay at home, how warm/humid their house is and how much moisture is in the air. The information will help to assist our local health and care organisations in their work to keep residents comfortable, safe, well and independent in their own homes.
Our Integrated Care Enablers are the driving force that helps to ensure that our plans for transformation can be delivered.
Organisational Development (OD) and Workforce: 10 Workforce Repository and Planning Tool (WRaPT) projects implemented across ELHT using £200,000 of funding. WRaPT enables a new type of workforce modelling, with the key assumption that changes to the workforce are predicated on changes in activity Volunteers Project: 12 universally recognised and transferable e-learning modules specifically designed for volunteers and linked to National Volunteer Certificate Standards d eveloped the Volunteer Learning Passport consisting of Estates: 4 suitable buildings Identified to allow our Neighbourhood Teams to work from the same office In 2018/19 we…
In 2019/2020 we will…
• Align plans across the health and care organisations, to ensure there is a ‘one plan’ approach to delivery
• Ensure that our workforce have the resources and skills to support people, of all ages, to live in their communities in a way that promotes health, independence and happiness
• Remove barriers to clinical service delivery and mobilisation of the workforce to allow for the delivery of improved services
• Commit to addressing the significant health inequalities in Pennine Lancashire and a shift ‘left’ of funding and resources towards prevention and self-prescribing
Together a Healthier Future Integrated Care Partners: