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Well Connected
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We aim to remove boundaries at the point that care is delivered, to create a system where patient interests come first and resources are collectively focused on improving health outcomes, supporting people to stay well and to live independently for as long as it is safe for them to do so.

Our providers (Worcestershire Health and Care NHS Trust, Worcestershire Acute Hospitals NHS Trust and Worcestershire County Council) work together with the Clinical Commissioning Group to deliver this goal by developing a new model of care; a model of care which delivers a connected system, designed and delivered around local people and located in natural neighbourhoods.  

There are four areas of focus for the Redditch and Bromsgrove Alliance Board: 

  1. Improving access to care
  2. Integrating primary, community and social care teams
  3. Promoting, prevention and self-care management
  4. Integrating specialist support areas (specifically frailty, diabetes and respiratory). 


Progress made in each area over the past year is described below: 


1. Improving access to care


  • There are several teams now piloting the Worcestershire County Council’s ‘three conversation model’, which is a strength-based approach designed to improve outcomes, promote independence as well as improve speed of response and reduce bureaucracy. This will be rolled out widely across Redditch and Bromsgrove in 2018.
  • Care Homes now have direct access to NHS 111 though a project called *6, giving them quicker access to support they need for their patients. 



2. Integrating primary, community and social care teams

  • Neighbourhood Teams have been developing plans, single points of access, one telephone number and co-location of staff. All neighbourhood teams in Redditch & Bromsgrove are now ‘live’
  • Several Neighbourhood Team Multi-Disciplinary Team (MDT) meetings have been running in Redditch and Bromsgrove for many months where the most complex patients are discussed. There is an on-going evaluation of the MDT meetings across Worcestershire and results will be available by the end of 2018
  • Care Homes are a priority for Alliance boards in 2018/19. We will be looking at ways we can support each neighbourhood team to make sure that care homes can access the appropriate support to keep their residents out of hospital if they can be cared for in their home
  • Population profiles developed for each team give information on the real issues each neighbourhood Team face, for example, the number of people with COPD or the number of people with dementia. These profiles will be used by teams to help identify their priorities moving forward 
  • There is a system being developed to enable links between all the various IT systems being used by different professionals. 


 
3. Promoting prevention and self-care management

There are two social prescribing pilots in Redditch and Bromsgrove. Pilot 1 in Redditch involves 9 GP practices in partnership with Worcestershire Association of Carers. Pilot 2, also in Redditch involves 2 practices using their own employed Social Prescriber

Practices are working together on a range of options to support staff and patients in delivering sustainable primary care using Care Navigation to support patients navigating around the system. In Redditch and Bromsgrove, patient and staff engagement was undertaken during 2017 which led to the development of the Healthcare Navigator model, with over 130 reception staff across 19 GP practices trained to be Healthcare Navigators.


4. Integrating specialist support areas
 

  • Two diabetes projects are now up and running. Firstly, providing Primary care and the Neighbourhood Teams with access to a Diabetes Specialist Nurse and secondly the development of a Diabetes Foot Care Team. 
  • There is a COPD Telehealth pilot being launched in Redditch and Bromsgrove. Although this is with a relatively small programme now, we plan to evaluate the benefits of using both Telehealth and a COPD phone application over the next year with a view to rolling out more widely if successful.