Joined Up Care Derbyshire Board – March 2021 – Key Messages
Patient Story – Integrated Care
The Board received a patient story relating to joining up care in Chesterfield as part of the Ageing Well programme. The holistic model of care has been developed since 2017 through the place alliance, specifically supporting housebound patient across three cohorts:
- People requiring a same day response
- People living in care homes
- People living with moderate frailty as risk of deterioration (proactive care).
A multi-disciplinary team including Long Term Condition Nurses, a Community GP, social prescribers, pharmacists, ACPs and paramedics has developed the approach which pre-dates the NHS Long Term Plan. Through proactive care planning, the project has seen a reduced requirement for multiple clinician input, greater continuity of care and greater levels of assurance for both the patient and the family that they felt supported and listened to, as well as having confidence that they were talking to clinicians who immediately were familiar with the details of the care plan.
Learning from this and other programmes is shared through the Place Alliances Leadership meeting which takes place monthly, where approaches and barriers are discussed and able to be adopted where there may be benefit. It was agreed that we should consider how we might broaden this learning to include other partners and to capture more formally the good practice that Derbyshire is driving.
The Board extended its thanks to everyone involved with the Covid-19 Vaccination Programme, including staff, volunteers and other partners who have worked tirelessly and brilliantly to deliver one of the most successful vaccination programmes in England.
Developing Our System
There has been significant progress in developing our system working at a time when there is such a focus on the pandemic. This was work in progress but has now been given increased focus through the recent publication of the Government White Paper on Health and Social Care.
Of note this month are:
- The progress in understanding how we accelerate provider collaboration at scale, working at system and pan system level to provide services for our patients, and at the same time building on significant progress in our place alliances by further developing collaboration at place for the benefit of local communities. Our existing eight place alliances will be known as ‘local place alliances’ in the future, with two Place Partnerships – one for the City and one for the County – supporting.
- The development of our interim ICS governance arrangements, where the Board was updated on the iterative process being taken to quality, performance, finance and people assurance during this transition year, overseen by a new Transition Committee.
- The emergence of the Clinical and Professional Leadership Group will build on the existing Clinical and Professional Reference Group to lead the development and delivery of the clinical model across the system. The starting point is to build upon what works well now, what can be consolidated and what will need to change fundamentally considering other ICS developments. These developments are key dependencies in relation to the development of wider clinical and professional leadership and there is a need for stronger engagement and alignment across various programmes of work. This is a complex process with many unknowns at this time; genuinely building stronger collective clinical and professional leadership which is meaningful will take time to transition and embed.
Our people plan continues to be guided by the three key assumptions that the health and social care system needs:
• More staff
• Working differently
• In a culture that is more compassionate and inclusive
Progress has included:
• Consistent support to staff across the system during the pandemic, with primary care staff having access to the Thrive app, and resources available to all through the JUCD website.
• The recovery of our workforce given the importance of their health and wellbeing and the impact this has on our ability to deliver our restoration and recovery plans must be a key principle in our planning for 2021/22.
• We employed 100% of the suitable Bringing Back Staff returners that were available to our system, which provided resilience during times of system pressure.
• System partners have collaborated effectively to resource and deploy the staff required for the vaccination programme in a very challenging context.
• We have implemented a range of employment access schemes in support of the Anchor Institutions work. The second Step Into Work programme concluded on 29th January; nine from the total of twelve candidates who commenced the programme on 7th December successfully completed the accredited courses and gained both Level 1 and Level 2 qualifications.
Childhood Obesity Strategy
The Childhood Obesity Strategy was developed in response to persistent obesity rates in children in Derby and Derbyshire. Anecdotal evidence and emerging data suggests that rates of obesity in children have increased in the last 12 months, including an increase in those who are severely obese. Further data will be collected during 2021/22 which will enable a new baseline to be set and agreement of outcomes targets.
The strategy recommends that:
1. Derby and Derbyshire develop clear pathways and signposting to enable children who are already overweight or obese to access joined-up and long-term support. This includes ensuring that there are robust systems in place to identify children who are overweight or obese and a commissioned service is available which provides effective support, in a multidisciplinary approach, to children and families.
2. Derby and Derbyshire develop preventative approaches for current and future generations and a whole systems approach to obesity which coordinates existing efforts, reveals gaps in provision and supports the efficient use of limited resources.