How ICSs are developing new ways of working to meet demand

How ICSs are embracing new models of care and new ways of working

How are integrated care systems approaching new models of care, new pathways, and new ways of working? We’ve taken a look at some of the projects and programmes taking place across England to explore the practical actions set in place.

Drawing on wider practice teams in Bath and North East Somerset, Swindon and Wiltshire

In Bath and North East Somerset, Swindon and Wiltshire, a focus is being placed on other practice-based clinicians to help expedite patient journeys to receiving “the most appropriate care and treatment”.

Care navigators ask patients about their condition at the time of booking an appointment, and then arrange treatment from the most appropriate healthcare professional.

Many practices also have dedicated mental health workers and community prescribers, who can recommend help and support in the community. Many non-GP practice staff are also able to do things like taking blood and prescribing medication, which are tasks which would once have required a doctor.

Dr Barry Coakley, deputy chief medical officer, said: “A GP practice is a high-functioning environment, made up of a variety of experienced colleagues, and we want our communities to understand the full menu of healthcare professionals available to them. In many cases, and especially for people with less-complex symptoms, it is quicker and easier to have a consultation with a member of the wider clinical team, such as a nurse practitioner or paramedic, than to wait for an appointment with a GP.”

Innovative workforce planning at Buckinghamshire, Oxfordshire and Berkshire West ICB

An initiative at Buckinghamshire, Oxfordshire and Berkshire West ICB, which focuses on finding new ways to organise and develop the workforce, has helped build an understanding of staffing problems and how to fix them.

Led by Human Resources teams from across the region, the initiative has conducted around 30 “deep dives” since 2020 to enhance understanding of key workforce challenges and how they might be tackled.

Raj Bhamber, chief people officer, said: “The challenges posed by the pandemic especially around staff shortages brought us all together to find solutions to ensure we could manage patient care better. This has included up-skilling staff and introducing new ways of working. We are now in a much better position to implement the national NHS Long Term Workforce Plan across BOB as we understand the needs and requirements of our own workforce so much better.”

Doctors, nurses and senior leaders supporting ambulances to help tackle delays in Norfolk and Waveney

Doctors, nurses and senior leaders are joining ambulance crews in Norfolk and Waveney, to help build an understanding of issues behind delays and identify ways to resolve them.

By joining ambulance crews, health and care professionals will be able to get an insight into challenges at each part of a patent’s journey into hospital.

Tracey Bleakley, CEO, said: “Staff from right across our health and care system are working extremely hard to provide the best care for our patients, in a timely way. We’re keen to hear their ideas and experience an average shift for ourselves. We will be joining the crew with an open mind and a solution-focused approach to how our health and care system can work together to ultimately reduce delays for local people, as well as ensuring better outcomes and experiences for our residents, staff and communities.”

New model to support patients living with long-term conditions in North Central London

People with long-term conditions in North Central London will be supported by a new model of personalised care intended to help them manage their conditions effectively and prevent escalation.

Designed around the Year of Care methodology, the model has been co-designed by residents of North Central London living with long-term conditions, as well as the local VCSE sector.

Holistic care will be delivered by teams across primary care and other system partners, including trusts, councils and VCSE organisations. Trials of the new model in Camden and Islington resulted in 1,027 new cases of people living with hypertension, and 500 new cases of those living with diabetes being identified earlier.

Individuals who have ben diagnosed or identified as at risk of developing long term conditions such as diabetes and cardiovascular disease, will be invited to a Yearly Health Check, which will help identify personal goals and actions for managing their conditions. Individuals will then be offered relevant support.

Admission Prevention Service expanded to all of Norfolk and Waveney

Norfolk and Waveney ICB has helped fund the expansion of an Admission Prevention Service which is providing support to those at risk of hospital admission and those who have been recently discharged.

The service aims to support people to “remain well in their own homes and communities, thereby preventing the need for hospital admissions or readmissions”. Initially launched in 2015, a pilot project proved effective in supporting individual needs in Norwich, before being rolled out to other areas of Norfolk in 2021. Now, it will be rolled out across all of Norfolk and Waveney.

Tracey Bleakley, chief executive, said: “We are thrilled to be working with Julian Support to make this much needed service available to all of our people across Norfolk and Waveney. Expanding this service will enable more local people to receive personalised care and support, helping to avoid an unnecessary hospital admission and to stay well in their own homes, which is so important to our health and wellbeing.”

Launch of Discharge to Access programme in Oxfordshire helps patients return home faster

A new Discharge to Access programme has launched in Oxfordshire to help support patients to leave hospital faster. Bringing together teams across health and social care, plans will be drawn up for each patient to be returned home more quickly, and to promote “a more joined up way to receive support once at home”.

In the days leading up to a patient’s discharge, Transfer of Care hub meetings will consider relevant information on each case individually, and within 72 hours of returning home patients will be assessed to ensure that they get the right kind of ongoing support.

To date, the pilot has achieved a 50 percent reduction in the number of days people are waiting to return home, helping 16 percent of patients return to independence with no ongoing care needs, and moving 28 percent of people onto the council’s Home First reablement pathway.

Tamsin Carter, head of the transfer of care hub, said: “This system is good news for all patients being admitted into hospital. For a person medically fit to be discharged, they may notice a greater sense of urgency to leave the ward and we would greatly appreciate the support of friends and family to help with this process. But with three days of free social care support planned for when a person gets back home, the outcomes are much better for people by recovering in their own home. We have already seen how more than a hundred patients have been supported through the system this summer and anticipate these trends to continue as we roll out the programme more widely throughout Oxfordshire.”

Enhanced Care Lounge opens in Bolton

We’re seeing new models of care come out of trusts too – at Royal Bolton Hospital, a new lounge has been opened with the aim of supporting vulnerable patients who are waiting to be discharged to a care or nursing home.

The Enhanced Care Lounge is designed to provide “physical and mentally stimulating activities away from the busy ward environment”, along with providing a comfortable setting in which patients can be prepared for a safe discharge. It includes an arts and craft zone, a living room, kitchen, and a hairdresser.

The lounge is set to run for a six-month trial with the aim of reducing length of stay, supporting complex discharges, providing patients with a ‘home from home’ environment to improve their experience, increase the number of patients who are suitable for discharge to care home, and improve staff experience too by reducing negative interactions. Additionally, it is hoped that the lounge will provide the opportunity for patients with cognitive impairments to leave their ward.

Joy Redwood, enhanced care and support team lead, comments: “Our new lounge provides us with an opportunity to work with patients before they leave us, interacting in different ways and offering care homes the chance to review patients by seeing them in a similar environment to a care home lounge.

“The quality of this care is already making a huge difference and it’s wonderful to see our patients and their families or carers enjoying the space and taking part in our different activities.”

In other recent news, NHS England has written to ICBs and trusts, asking them to complete a “rapid two-week exercise” to address the financial challenges created by industrial action, and agree actions required to deliver priorities for the rest of the financial year.

Last month, we looked at how ICSs are taking action to increase winter preparedness, in light of increased operational pressures during the winter months.