Building a Health & Wellbeing Network

Context

“Cambridgeshire and Peterborough is one of 11 most financially challenged health economies in England”. A high growth area including two new towns (estimated 15,000 homes) and predictions of 44% increase of over 65s by 2021.

In 2013, Cambridgeshire and Peterborough CCG began the bid for the older person’s service, the first of its kind in the country the aim of which was to shift the focus from acute to prevention.

The tender for the older persons service was predicated on a £800 million contract to provide cross sector support to people aged 65 years and older and people with Long Term Conditions in Cambridgeshire and Peterborough. Embedded within this contract was £1 million to third sector organisations for current service delivery, but also an opportunity to help develop a new wellbeing service.

In addition to this, there are a number of Health and Social Care change programmes across Cambridgeshire and Peterborough aiming to address / improve health and well-being;

The Public Health team across Cambridgeshire and Peterborough are running a programme called ‘Healthy Ageing and Prevention’ on behalf of the Cambridgeshire Executive Partnership Board. (includes third sector)

Priority 3 for the Cambridgeshire Health and Wellbeing board is; ‘Encourage healthy lifestyles and behaviours in all actions and activities while respecting people’s personal choices’.

‘Transforming Lives’ is Cambridgeshire County Council’s in-house change programme, looking at establishing and streamlining services access across Tiers 1, 2 and 3. People identified as Tier 1 will need to have access to a range of health and well-being /preventative services.

‘Investing in Communities’ is Peterborough City Council’s in-house change programme. Cambridgeshire and Peterborough CCG is one of the national Urgent and Emergency Care

Vanguards. The CCG have established a Strategic Systems Resilience Group (SSRG) that is county wide. One of its 5 strategic aims is; ‘Promoting self-management and self-care’.

Whilst Cambridgeshire and Peterborough has a vibrant third sector it is made up of mainly small organisations delivering in small geographical areas.

Thinking differently – drivers for change

CVS5 – the consortia of CVSs in Cambridgeshire/Peterborough worked in conjunction with Cambridgeshire & Peterborough CCG in raising awareness within the sector of the outsourcing of the older people’s service.

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During the tender period third sector organisations were targeted and courted by bidders, larger organisations coped with the demand for meetings and information; smaller organisations struggled to get their voice heard.

The vision - integrated health & wellbeing third sector

With this system wide focus on prevention and healthy ageing, there is a great opportunity for a coordinated third sector to demonstrate the breadth of services it can offer and establish itself as an innovative leader in interventions that support improvements in quality of life. As a united and consistent collective, the development of a ‘The Health & Wellbeing Network’ providing a single point of contact for both professionals and services users.

The aim of a more unified approach was to;

Improve accessibility of services. Streamline commissioning / performance management. Raise the profile of voluntary organisations, encouraging them to play a wider role in

prevention and support statutory services to manage ever increasing demand.

The Health and Wellbeing Network

Developing the ‘offer’

1. Defining ‘the needs’ that ‘The Cambridgeshire and Peterborough Health and Wellbeing Network’ may support

In order to provide a coordinated and easily accessible service whilst also demonstrating its impact on health and well-being, ‘The Cambridgeshire and Peterborough Health and Wellbeing Network’ needed to be very clear on what interventions it will provide. The below list is based on an initial scoping exercise completed and categorised using the Rockwood Frailty Scores / Local Authority tiers of function.

Fit and Managing Well(Tier 1, Rockwood 1-3)

Vulnerable (Tier 2, Rockwood 4-6)

Frail / Significant Need(Tier 3, Rockwood 7-9)

Nutrition / Hydration Befriending Admission AvoidancePhysical Activity Access Housing Support Carer InterventionSocial Clubs / Forums Housing Adaptations Home from HospitalEducation Opportunities Housing Access Care Package AugmentationVolunteering Opportunities Condition Specific Groups Mental Health crisisAccess to literature and web Shopping Dementia/Delirium crisisSupport Telephone Line Transport MDT supportSignposting Bin collections End of Life Telephone Preference Service Assistive technologyMail Preference Service Financial well being

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AdvocacyCarer SupportMental health supportDementia / Alzheimer’s supportPharmacy / Medication supportPet CarePhysical and Sensory support

It is felt that Tier 1 services are those provisions that are low risk and could be provided by a variety of local voluntary sector groups and organisations, and do not necessarily require significant structure / governance around their reporting or activity.

2. Coordinating members service delivery

To ensure people are accessing the most appropriate intervention, from the most appropriate service in a timely way, ‘The Cambridgeshire and Peterborough Health and Wellbeing Network’ needed to work with its member organisations to define which providers will deliver against each need. Each member organisation should have clear parameters if they are delivering an intervention about what information they need to share centrally with the Health and Wellbeing Network, and adhere to time frames required for reporting.

The Health & Wellbeing Network should define what the service offering is for each Tier 2 and Tier 3 intervention, so that various organisations delivering the same service in different localities have similar outcomes. Clarifying the service definition for each intervention will also improve commissioners’ understanding of what the Wellbeing Service is delivering and help make the case for on-going funding or increased funding if we want to expand services. For example, a Home from Hospital service should have operational models that mirror each other wherever possible and the performance data gathered for each service should be the same. For the Home from Hospital intervention, example universal data may be; how many new patients were supported each month, length of time each patient was supported, what specific support was delivered (i.e. shopping, cooking, daily visit to reduce anxiety etc)

3. Single Entry Point and ‘The Cambridgeshire and Peterborough Health and Wellbeing Negtwork’ Marketing

Navigating the Cambridgeshire and Peterborough Health and Wellbeing Network needs to be as simple as possible for professionals and the public. A single phone number is available for enquiries and referrals and the call centre support would then manage all onward referrals out to the most appropriate Wellbeing Service organisations. In addition to the phone number a web site and simple internet referral process has been developed that is based on the needs/interventions that the services under the banner of ‘The Cambridgeshire and Peterborough Health and Wellbeing Network’ provide.

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Both a phone number and website could be linked directly to 111, and to the new ‘DXS’ information system being rolled out to GPs, contact centres at local authorities etc etc. The diagram on the following page show the various groups / services that may refer into ‘The Cambridgeshire and Peterborough Health and Wellbeing Service’

All referrals via a call centre should be logged within a single repository IT system (see section 5 below). This would mean that a client only has to give their details once and then this information can be shared (subject to appropriate consent) with the relevant ‘Cambridgeshire and Peterborough Health and Wellbeing Network’ organisations providing the interventions. To manage the work load of referrals coming into the wellbeing service, it is felt that a staggered approach to introducing a

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wellbeing call centre would be ideal, with a launch specifically to GPs in the first instance and then spreading out to other professional groups, before going wider to more public domains.

For external marketing purposes and to improve utilisation of Wellbeing Service, individual organisation materials would need to be limited. Commitment will be required from all ‘full’ member organisations to move towards a unified marketing approach for ‘The Cambridgeshire and Peterborough Health and Wellbeing Service’ (different membership levels are described in sections 7 and 8). Individual organisational materials could be handed out when a service is directly working with users but only once a ‘Cambridgeshire and Peterborough Health and Wellbeing Service’ referral has been processed and an intervention put into place. An example of this may be; if a patient requires admission avoidance support, Age UK may provide the intervention and then leave the patient with some further information about Age UK’s other services, and other appropriate members, e.g. Dial Peterborough, whilst the service is being delivered.

4. Capturing Activity Information – A Single Repository

If all members were to input information into a single IT system/repository, progress with interventions could be reviewed centrally. In addition, the centralised repository system could also allow members to report key performance / activity metrics that could be used to generate a performance dashboard for ‘The Cambridgeshire and Peterborough Health and Wellbeing Service’ as a single entity. This report could then be shared with the various commissioning organisations. Performance data should be relevant to the interventions delivered and reflect the relevant outcomes, rather than just the most easily measured.

Data from a central performance dashboard could also be used in any joint tender opportunities that ‘The Cambridgeshire and Peterborough Health and Wellbeing Service’ member organisations may want to bid for.

5. Universal Outcome Measures

Cambridgeshire and Peterborough CCG and the Local Authorities are keen that all statutory and non-statutory support services begin to gather universal outcome data, to measure the impact of interventions and help define what level of support the population may need. There are two measures that should be captured during an intervention that is delivered by any member of ‘The Cambridgeshire and Peterborough Health and Wellbeing Service’; Frailty score and a Quality of Life (QoL) measure.

The ‘Frailty Score’ can be obtained using the Rockwood Clinical Frailty Scale. This defines what level of need a patient has from 1 (very fit) to 9 (less than 6 months to live). Assessing a client prior to an intervention will allow ‘The Cambridgeshire and Peterborough Health and Wellbeing Network’ to identify the types of clients it is supporting. Frailty scores should either be provided by a referring professional or assessed at the first face to face contact with the organisation delivering an intervention.

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In addition, it may be that the interventions delivered by ‘Cambridgeshire and Peterborough Health and Wellbeing Network’ organisations are not specifically implemented to improve frailty or physical ability but they are implemented to improve quality of life. As such, a measure should be introduced that assesses someone’s own perception of their quality of life, which should be carried out pre and post intervention. The quality of life measure that is used needs to be defined by the commissioning organisations.

6. Membership and Management

The Cambridgeshire and Peterborough Health and Wellbeing Network membership should be an inclusive right for all Voluntary sector organisations across Cambridgeshire and Peterborough. There could be a distinction between ‘Full’ Members and ‘Network’ Members (please see Governance and Reporting Structure for suggestions as to what could constitute Full vs. Network membership). The different levels of membership may denote the type of interventions a service delivers (Tier 1, 2 or 3), what is expected in terms of reporting and what level of rigour is required over the quality / background check / training of active volunteers.

It is proposed that the Health and Wellbeing Network would need a small operational team to coordinate members, develop performance management processes and reports, manage marketing and promotion, liaise with commissioning teams and programme boards around performance of its services and help to identify additional interventions and potential funding support for new interventions that members of the Health and Wellbeing Network may want to deliver.

For more information please contact

Julie Farrow

Chair Health & Wellbeing Network

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