Agenda

MeeLlng: enwlLh loneer rogramme

uaLe: 19
Lh
March 2014
1lme: 09:30 - 11:30
venue: Med 2 Semlnar room WesL Cornwall PosplLal, enzance
Lead 1lmlng
(Mlns)
1. Welcome and Apologles Chalr 10
2. Local eople and Local ConversaLlons !l 43
3. Work SLream updaLes
eople and SLakeholders
Workforce
LffecLlve AsseL uLlllsaLlon
lnformaLlon Covernance and 1echnology
CuLcomes and lnLelllgence
lnLegraLed Commlsslonlng
Leads 43
4. revlous MeeLlng 8ecord
PlghllghL 8eporL
8lsk 8eglsLer
l
o
r

d
l
s
c
u
s
s
l
o
n

b
y

e
x
c
e
p
L
l
o
n


3. Any CLher 8uslness Chalr 10
6. uaLe of nexL MeeLlngs
16
Lh
Aprll 2014 [ 9:30
luLure meeLlngs every 3
rd
Wednesday of Lhe monLh






MeeLlng 8ecord

MeeLlng: enwlLh ro[ecL 8oard
uaLe: 19
Lh
lebruary 2014
1lme: 09:30 - 11:30
venue: Med 2 Semlnar 8oom, WesL Cornwall PosplLal

!"# %&'()''&*+ ,*&+-'
resenLaLlon and revlew of Lhe 8esearch and LvaluaLlon acLlvlLy for Lhe loneer
rogramme
o See appendlx for slldes
newquay aLhflnder 8esulLs
o See appendlx for slldes
eople and SLakeholder Work SLream
o Wlder sLakeholder lnvolvemenL needs Lo be developed
o Comms messages need Lo be speclflc and person focused
o Comms Leam need Lo develop a slmple gulde
Workforce
o 1he LocallLy 1eam has been meeLlng every 2 weeks.
! Agreed Lhe crlLerla for person selecLlon
! Crganlsed a [olnL sesslon for newquay and enwlLh Leams
lnLegraLed Commlsslonlng
o 1hls work sLream has noL been formally esLabllshed yeL, however Lhere are
on-golng dlscusslon aL Lhe CounLy loneer level focuslng on Lhe 8eLLer Care
lund.
lnformaLlon Covernance and 1echnology
o 1here ls a naLlon loneer workshop on 28
Lh
lebruary
CuLcomes and lnLelllgence
o Workshop held and acLlons agreed
o aLhflnder reporL flnallsed and publlshed
AsseL uLlllsaLlon
o Cn golng dlscusslons abouL poLenLlal offlce accommodaLlon

%"(&'&*+'
ubllc PealLh Lngland Lo faclllLaLe a sesslon Lo focus and llnk research quesLlons

.(-&*+' Cwner ueadllne/
CompleLed
1. ClrculaLe ACC naLlonal ueclslon Model, roll ouL Lo all work
sLreams and all members Lo Lry before nexL MeeLlng
!W/S8/All
!
2. Leadershlp SummlL Lo adopL ACC naLlonal ueclslon Model 18/AA
!
3. PW88 Lo adopL ACC naLlonal ueclslon Model !M/S8/!W leb 2014
4. loneer naLlonal 1eam Lo revlew ACC naLlonal ueclslon
Model
!L leb 2014
3. resenL Lhe loneer rogramme Lo Lhe 1own and arlsh
Counclls ln enwlLh
!M/Sn Lo
arrange
Mar 2014
6. MeeLlng wlLh LdlLor of 1he Cornlshman/WesL 8rlLon !M Lo Mar 2014

"##"$%&
'( )&"*&#+,-. /011-2 23 4& "+5&* 23 *&6-$& 2,&-# 7 8&"# 9-+-3$ ::;<= >"# ?@AB
C( D&2E3#5 )&"*&#+,-. F#30. 23 4& 4#-&6&* 3$ 2,& G&$E-2,
G-3$&&#
DH;>I >"# ?@AB




Highlight Report Penwith Pioneer

Title: Integration Penwith and Newquay
Responsible Officer: Tracey Roose

Completed tasks for reporting period from: 19
th
February 2014 to 19
th
March 2014
Programme Management

Programme Board The programme board will meet on 19
th
March 2014

Integrating commissioning Work Stream
Strategic Commissioning Workshop with Social Finance, Alliance Commissioning and Financial Consultant
Outcomes and intelligence work stream
Finalise operating principals
Finalise indicators against the triple aim for Penwith
Information governance and technology work stream
Scope the information requirements for Penwith
National Information Governance Workshop
Workforce development work stream
Newquay and Penwith Workshop
Locality Team
People and Stakeholder Engagement Work Stream.
Run community asset speed dating event
Develop user and carer involvement in co-production of the service
Asset Utilisation Work Stream


2
Operational Delivery

Staff
All 4 members recruited. Ruth Tod, Josh Clarke, Becky Keverne, Cally Pawley. Ruth and Josh fully inducted, Becky and Cally
will be in 1 2 weeks. Shadowing opportunities being accepted with D nurses and Comm matrons
Carolyn Trevethick, team leaders post being covered by Jenny Atkinson.
Helen Schnasell, Volunteer Cornwall is working very closely with the team supported recruitment and management of
volunteers and community engagement
1 volunteer, retired nurse, currently being inducted, further 3 being followed up.

Resources
Team all have PCH honorary contracts, access to internet via novell, therefore ability to remote access Age UK Cornwall
electronic systems for data input / storage and also all have groupwise accounts.
All staff based at Bellair. Health teams in Bellair very welcoming and supportive but allocated space only suitable for 1 2
staff, so working conditions are tricky. Jayne Allen ( DN team leader) being v helpful at looking at alternative options. GP
practices also very cramp for space.
Suitable IT system, RIO, being instigated through CPFT. Time scale is 4months.

Volunteer recruitment
PPG, key community groups, OP Forum eg WI, U3A, being targeted, several talks taken place. Advert on do it website, in
local press and posters / flyers in process of being developed.
Discussions re streamlining recruitment process, making it safe yet appropriate underway.
Mapping and visiting of community resources and groups well underway, including singing for the brain, memory cafes, day
centres, Friday morning coffee club, Giving shop, local domiciliary agencies, self help groups, church groups

Engagement
Alverton, Rosmellyn, Penalverne, Sunnyside and Cape Cornwall practices have all been visited and have signed up. Morrab
to do shortly. Hayle, Marazion and Stennack to follow in 2 /12.
Data protection confidentiality clauses signed in most practices. Only Rosmellyn are referring ( and Matthew Boulter) at
present from the practices. Discussions around promoting referrals in place. Referrals being received from D nurse teams,
comm matrons, discharge nurses, EIS, physios
Invites and attending MDT meetings are Sunnyside, Alverton and Rosmellyn, EIS, DN. Regular contact with Comm matrons,
Wof C hosp.

Communication
Paperwork being reviewed and adapted to Penwith and RIO. Process for sharing information following referral what matters
to me and what are my action plans and feedback being defined with practice managers and other referrers.
Consent for info sharing being reviewed via RIO.
NB area of potential risk is the duplication of NHS numbers. Discussions on how to mitigate this risk being discussed with
Practice managers.

Programme Communications
Coms strategy developing
Visit by Norman Lamb Minister for Social Care
Publish Newquay Pathfinder Report
Health and Wellbeing Board discussion


3

Tasks to be completed for reporting period from 19
th
March 2014 to 16
th
April 2014
Programme Management

Programme Board The programme board will meet on 16
th
April 2014

Integrating commissioning Work Stream
Strategic Commissioning Workshop with Social Finance, Alliance Commissioning and Financial Consultant

Outcomes and intelligence work stream
Develop performance dashboard
Initiate financial modelling work

Information governance and technology work stream
Resolve risk stratification information governance issues

Workforce development work stream
The Locality group will run a My Journey workshop with people

People and Stakeholder Engagement Work Stream.
Further develop user and carer involvement in co-production of the service

Asset Utilisation Work Stream
Identify funding for potential shared office

Operational Delivery
Work with remaining practices
Work with trainee GPs to accelerate recruitment of people to the programme
Programme Communications


Project Status: Green On time? Yes

Milestone Status:
Milestone Target Date Current Estimate Date Within Tolerance
To be confirmed to be co-
designed and agreed through
workstreams and programme
board



Problems, Issues or Good Practice:



Decisions required from Project Board:

4

To note the risks associated with the Risk Stratification issues.


Name: Scott Bennett & Emma Rowse Role: Consultants Date: 19
th
March 2014


Risk Register Newquay and Penwith Pioneer 19th March 20143
Mitigating
actions
(a) actions
taken to date
(b) actions
intended to
be taken
(c) controls
that are in
place
1 Deployment
and quality of
Risk
stratification
Tool
Impact on
identification
and
monitoring of
patients
5 4 15 KCCG to
progress
ASAP
b - priority
issue for
KCCG
GR/SB ASAP Amber Risk Strat
tool based
on
secondary
care in
place.
Results
have been
questioned
Mar-14 A
2 Lack of
information
sharing policy
Failure to
share patient
information
5 3 15 Agree new
information
sharing
arrangements
b - Priorities
policy
agreement
SB, ER,
BG
ASAP Amber IG & IT work
stream
prioritising
this
Mar-14 A
3 Lack of
baseline data
Failure to
define the
social issue
5 3 15 Prepare
evidence base
a - Building
evidence base
SB, RM ASAP Amber O & I Work
Stream
prioritizing
this
Mar-14 A
C
h
e
c
k
e
d
N
e
t

R
i
s
k
R
i
s
k

S
c
o
r
e

(
G
r
o
s
s
)
R
e
f
.
R
i
s
k
I
m
p
l
i
c
a
t
i
o
n
S
i
g
n
i
f
i
c
a
n
c
e
L
i
k
e
l
y
-
h
o
o
d
S
t
r
a
t
e
g
y
B
y

w
h
o
m
?
B
y

w
h
e
n
?
R
i
s
k

S
t
a
t
e
C
o
n
t
i
n
g
e
n
c
y

P
l
a
n
Risk Register Newquay and Penwith Pioneer 19th March 20143
Mitigating
actions
(a) actions
taken to date
(b) actions
intended to
be taken
(c) controls
that are in
place
C
h
e
c
k
e
d
N
e
t

R
i
s
k
R
i
s
k

S
c
o
r
e

(
G
r
o
s
s
)
R
e
f
.
R
i
s
k
I
m
p
l
i
c
a
t
i
o
n
S
i
g
n
i
f
i
c
a
n
c
e
L
i
k
e
l
y
-
h
o
o
d
S
t
r
a
t
e
g
y
B
y

w
h
o
m
?
B
y

w
h
e
n
?
R
i
s
k

S
t
a
t
e
C
o
n
t
i
n
g
e
n
c
y

P
l
a
n
1
Policy Innovation Research Unit
(PIRU)
Independent expert advice on relevant
indicators for use by Pioneers to monitor
their performance over time and by the
subsequent evaluation
Early evaluative study focusing on the
first 15 months of the Pioneers and
the first year of the Integration
Transformation Fund (ITF)
Nuffield Trust Evaluation
Use data linkage techniques to look at
healthcare utilisation and associated costs for
patients receiving Age UK services in Cornwall
and elsewhere, and to compare their patterns
of NHS care to a matched control group.
One of the key questions will be whether Age
UK services led to significant reductions in
hospital use for the period following the
intervention.

South West Peninsula Academic
Health Science Network

Proposing a comparative study of 3 projects
Pioneer - Cornwall and Devon and the Symphony
Project - Somerset
Outcomes and financial impact

University of Exeter - Evaluation

Research focus on volunteers
How to build capacity in communities for social
care for the elderly
Public Health Englands Offer

Evaluation scoping
How to demonstrate impact on public health
Prevention metrics short / medium term
Exploring tools and guidance returns on
investment
Local research and evaluation
options

Experience of patients
Pre / post study of care and support on the
programme
Changes to quality of life
Self-reported health and wellbeing e.g. measure of
loneliness

Experience of volunteers
Experience of staff how they feel about working in an
integrated way
2
Next steps

Map out what is happening developing a strategy
Draw on expertise from Public Health England e.g
faciliated session on research and evaluation
Identifying the gaps
Use the triple aim as a framework
Improve health and wellbeing
Improve experience of care and support
Reduce the cost of care and support
Link with national PIRU evaluation
16/03/2014
1
People, Place, Purpose
Shaping services round people
and communities through
the Newquay Pathfinder
Measuring impact
Improved quality of life Outcome 1
Individual self worth and social capital
Improved connectivity
Community resilience
Enabling economic viability
Interdependent teams Outcome 2
Greater satisfaction
Enabling decision making
Financial Outcome 3
Reducing/compressing spend
Identifying funding shifts across system
Outcome 1
Quality of Life
!"
$%"
$&"
%'"
%("
Outcome 2
- Integrated working
!)" *+,- ./0,1 2+./34-01 5617
5+* 8019 61 0:.10;0<9
;0+4,4=>?<
!)" *+,- ,4.0=1+@64 5+*
5617,4= 8019 61 0:.10;0<9 50<<
AB C0<,080 ./+. ./0 2+./34-01 5+* ./0 ;,**,4=
<,47 ,4 *018,D0* >61 ./0 *018,D0 ?*01E F6;C,40-
5,./ /0+<./ *?2261. +4- *?2261. >16; G-?<. D+10
+4- 50<<C0,4=H ./0 2+./34-01 ,* +C<0 .6 2?. ./0
201*64 +. ./0 D04.10 6> 216D00-,4=* +4- 34- 6?.
5/+. ./09 5+4. +4- *?2261. ./0; .6 ;+4+=0
./0;*0<80* +4- ./0,1 D64-,@64* .6 ./0 C0*. 6>
./0,1 +C,<,@0*E I/,* ,* ,4D10-,C<9 ;0+4,4=>?< .6
./0 ,4-,8,-?+<EJ !"#$ &"$'"(
Outcome 2
- Integrated working
Outcome 3
- Reduced Cost of Care and Support
"
#$
%$
&$
'$
($
)$
"
%$
'$
)$
*$
#$$
#%$
#&+$)+%$#% #&+$,+%$#% #'+#%+%$#% #)+$&+%$#& #)+$)+%$#&
!
"##"$
%
&

(
)
$
*
&
+
%
,
&

-+.)/%,012 3$&.& $4 %$%50#03670 +,8"&&"$%& 701&*& 09:03.+6$% +%, :$:*#+6$% #070# 3$8:+1"&$%
-./012345 46748/43 89:/ /9 3./4;; -./012345 .8/<.= 89:/ /9 3./4 >6748/43 797<=.?92 89:/ /9 3./4 @8/<.= 797<=.?92 89:/ /9 3./4
16/03/2014
2
Outcome 3
- Reduced Cost of Care and Support
!"#$%&"' )%#$ *%+,-"./
0',.1&"% 2 was Lo measure pre-aLhnder days
back Lo Lhe polnL of rsL hosplLal admlsslon for
L1C for each pauenL.
0',.1&"% 3 was Lo Lake Lhls daLe and add a furLher
year Lo each pauenL.
Outcome 3
- Reduced Cost of Care and Support
Summary
)%4.$,& 51'$41- *%+,-"./
6%. 7-,'89, :+;"##"%.# 0<,.+
30/66 8educuon
=>) 6%. 7-,'89, :+;"##"%.# 0<,.+
40/63 8educuon
!"#$%&"' 0<,.+ *%+,-"./
?.+,& 0',.1&"% 2
36 8educuon
?.+,& 0',.1&"% 3
23 8educuon
Outcome 3
- Reduced Cost of Care and Support
Outcome 3
- Reduced Cost of Care and Support
Outcome 3
- Reduced Cost of Care and Support
16/03/2014
3
!"##$%&
()*+%,-"./01 21 .034 05 0160216
.$%, 7$.8$6,3
9,-"./01 21 ,:7,.4,- -,#$1- 50%
1,; 7$.8$6,3 05 .$%,
!"#$%"& !%()"& !*+$#,"
!"#$%&' )*+,%-*) #+./&0 $*.$1* #&0
-.22/&%3%*) 3"+./'" 3"* 4*56/#7 8#3"!&0*+
-#* .+"(. /" %01" (
2*/(3 4"035 (36
3#. (3 #%6 7#+3
#*. .2035 03 ( )2(0+
! # !"#$%"& !%()"& !*+$#," - ./" 0"12*(3 !(4/!56"+ !+#7")4
8*+ 2*9"4 +":#%*49#5 /(, )/(5;"6 4/"
<"/(:9#*+ #= ":"+3#5" 1/# /(, <""5
95:#%:"6 (56 /"+" (+" ,#>" #= 4/"9+ ,4#+9",
Alfred, who lost his
wife and his confdence,
kept having falls and
was worried about being
a burden; now he is
more mobile and hosts
a regular social group at
his home
Daphne, who spent long periods
in hospital following repeated falls,
had dementia and was living in one
room, highly dependent on carers;
now she can move about the house
and get to the bathroom to wash
her hair, which was what she really
wanted to do
Edward, who fell in the garden and was unable to move for ten hours
and became anxious and depressed about leaving the house; he and a
volunteer started talking together over a cup of tea at home and gradually his
confdence increased so that he could go out once a fortnight to a nearby caf
- now he regularly attends a walking group and has had no further falls
Beryl, who was fnding it hard to
get about afer 12 days in hospital
following heart failure; she has
attended over 20 support groups
and social events, regularly shares
her experiences with new groups
and has not been in hospital since
Catherine, who was becoming
more reliant on her husband and
had diabetes, heart disease and
dementia; now goes on outings
independently as well as sharing
activities with her husband, who
said that the support they had
probably saved him from having a
breakdown
!"#$%"& !%()"& !*+$#," - ./" 0"12*(3 !(4/!56"+ !+#7")4 " #
Te district nurse when
delivering a commode to an
individual who was at risk of
falling, asked herself what am
I doing shrinking this persons
world, turned around and
returned with a volunteer falls
prevention buddy
Te pharmacist who
decided that he would
train one of his team to
work in an integrated
way and do home visits
for everyone on the
Pathfnder
Te commissioner who
said that for years, she has
been commissioning the
wrong things.
Fred, who has diabetes and recently had a stroke, reliant on frequent
home visits from nurses and care staf; now he is able to go out and about
and recently hosted a social event at home he has also reduced his own
care package
Te GP who genuinely talks
about how it has transformed her
thinking and the lives of people
she had thought were at the end
of the line - now she has more
magic to ofer people than simply
medication
Te performance manager who
said that designing a shared
outcomes framework had
connected her to improving the
lives of real people the most
inspirational project Ive ever
worked on
A volunteer who retired early
due to stress as a teacher, now
has a part time counselling job
which she loves as a result of her
involvement with the pathfnder
and still volunteers for us
!"#$%"#&
'"()$()*
+,$ ."()#/01)/"( "2 ),$
2"33"%/(4 "#45(/*5)/"(* /(
&$6$3"7/(4 5(& &$3/6$#/(4
),$ 7#"4#588$9 5* %$33 5*
7#$75#/(4 ),/* &".18$() /*
4#5)$2133: 5.;("%3$&4$&
__ Newquay PaLh!nder Summary
6 __ ackground
7 CohorL denL!caLon and characLersLcs
7 Shared ManagemenL Plans
8 The Newquay Leam
__ OuLcome Perormance
OuLcome One - mproved Wellbeng and QualLy o Le
OuLcome Two - nLegraLed Workng Works
1O OuLcome Three - keduced cosL across Lhe whole sysLem
1O CosL o non-elecLve acuLe admssons
1O Conclusons
11 _ Lessons LearnL
11 WhaL Worked Well
11 kecommendaLons
+,$ <$(%/), </"($$# <#"=$.) >"5#& %"13&
3/;$ )" /()#"&1.$ 5(& $(&"#*$ ),$ #$*13)*
2#"8 ?$%@15: 75),!(&$# 5(& %$ 5#$ 3"";/(4
2"#%5#& )" 01/3&/(4 "( ),/* %"#; %/), ),$ #"33
"1) "2 "1# '"#(%533 </"($$# 7#"4#588$A +,$
)$.,(/.53 $65315)/"( #$7"#) %/33 0$ 7#"&1.$&
0: B4$ CD (5)/"(53 5(& %$ %"13& 3/;$ )" ),5(;
),$8 2"# ),$/# *10*)5()/53 ."()#/01)/"( )" ),$
?$%@15: <5),!(&$# 7#"=$.)A
E# F5),$% >"13)$#
',5/# "2 <$(%/), </"($$# <#"=$.) >"5#&
!"#$%"& !%()"& !*+$#," - ./" 0"12*(3 !(4/!56"+ !+#7")4 " #
0"12*(3 !(4/!56"+ 8*99(+3
!+#:+(99" ;<,<#5
To mprove Lhe qualLy o le or older people n Newquay by helpng Lhem denLy ways Lo buld
Lher sel-con!dence and sel-relance, provdng pracLcal supporL Lo help Lhem acheve Lher
aspraLons. Ths reduces dependency on healLh and socal care, ncludng hospLal admssons.
!+#:+(99" #*4)#9",
1 Improved health, wellbeing and quality of life
2 Integrated working works
3 Cost reduction across the whole system
./" ,"+;<)"
Targeted wrap around support motivating at-risk
older people to achieve their aspirations through a
guided conversation
Individuals are supported by an Age UK worker to
identify their goals and to co-ordinate a management
plan that is delivered by coordinating statutory and
community services and support
Te support using volunteers aims to build peoples
social networks, making them better connected to
their community and more resilient
Age UK worker is part of a multi-disciplinary team
which includes GP, district nurse, matron and social
workers
./" ="5"!4,
23% improvement in peoples self reported wellbeing
87% of practitioners say integration is working very
well and their work is meaningful
30% reduction in non-elective admission cost
40% drop in acute admissions for long term
conditions
5% cost reduction and reduction in demand for adult
social care
><:/%<:/4, (56 ?55#;(4<#5
Guided conversation starting point is a
conversation between equals, with time to listen
to the persons story and to understand their
motivations and aspirations
Ripple efect change of clinical practice observed
within the integrated care team as staf (particularly
district nurses and GPs) sought to proactively reduce
dependency rather than control risk
Joint working between partners to develop and agree
a joint performance framework, with Age UK being
the central data processor
What started as a conversation became a quiet
revolution as practitioners worked across
organisational boundaries to focus on the people they
were supporting
8*99(+3 #@ A"3 B")#99"56(4<#5,
We must continue to develop the model and test this
with other population groups in Cornwall focusing
on a whole person/whole life approach
Leaders must understand that transformational
change is complex, messy and doesnt ft neatly into a
project box
Agree a methodology for cost/beneft data analysis
up front and defne an evaluation framework at the
start
Identify innovators and champions at all levels in
organisations, engage their passion and use this to
create sustainable change
! # !"#$%"& !%()"& !*+$#," - ./" 0"12*(3 !(4/!56"+ !+#7")4
8()9:+#*56
Over 1,000 people and 40 organisations came together to discuss
what we loved and what we wished for as we collectively grow
older in Cornwall. Our Wall of Wishes and Trees of Talent began
a dialogue with our community which has changed the way
we provide and deliver services and resulted in the Newquay
pathfnder.
What we heard loud and clear was that people want to be at the
centre of services we deliver. Tat we should focus on the skills,
experience and talent people have, reshaping what we ofer around
a conversation with them.
Tis learning was the foundation for the Newquay Pathfnder and
there are three pillars to the approach:
!" $%&%' ()* +, -./"0122 1"3 45* !62*6 .7 89:22;' 0:45 6<==./4 7/.> ?<95; @*1245'
A.2<"4**/ -./"0122' 2.912 1<45./:4;' 5*1245 1"3 =/:B14* 6*94./ =1/4"*/6' :"B:4*3 .23*/
=*.=2*' 91/*/6' /*214:B*6 1"3 >*>C*/6 .7 45* -./":65 9.>><":4; 4. D.:" 45*> 4.
9*2*C/14* ()* 1"3 (>C:4:."E
;< =4 ,4(+4, 1>4/ ( )#5?"+,(4>#5@
Changing lives is about conversations - with individuals, with
practitioners and with communities
It starts with peoples aspirations, understanding their story
and supporting them to reach their goals
It is about trust and relationships that matter. Seeing people as
human beings who have skills and experience to contribute to
their community and their care.
A< =4 )/(5:", 4/" 1(3 1" %>?"& 4/" 1(3 1"
1#+9 (56 4/" 1(3 1" B""%@
People who were patients becoming volunteers, people who
were volunteers becoming practitioners, people who were
practitioners becoming radical champions for change
Giving practitioners permission to work collaboratively across
organisations, responding to peoples aspirations
People feel they can reach their goals and feel confdent to play
an active part in their community
C< =4 >, ,*,4(>5(D%" (56 +"$%>)(D%"@
Te programme is based on people and the resources in a
community so that each individual and locality can shape their
own solution
Robust, shared performance monitoring ensures we can
demonstrate and monitor delivery
!"#$%"& !%()"& !*+$#," - ./" 0"12*(3 !(4/!56"+ !+#7")4 " #
Case
management
Very high
relative risk
0.5%
High
relative risk
0.5% - 5%
Moderate
relative risk
6% - 20%
Low
relative risk
21% - 100%
Disease
managememt
Supported
self-care
Prevention and wellness
promotion
8#/#+4 96"549!)(49#5 (56
)/(+()4"+9,49),
Te cohort was identifed using a primary care risk stratifcation
tool and then matched against agreed criteria. People were
selected if they had a high risk of a hospital admission and had to
have at least two long term conditions that had the potential to be
managed in a community setting.
Te fnal phase of the selection process was to review the cohort
list with practitioners to screen out those people who had a
terminal diagnosis, clinical need for a regular hospital admission
or would not respond to the Newquay approach.
Our Newquay pilot was based a small sample of 106 people the
majority of whom were female and over the age of 85. Only 27%
of those in the pilot had ongoing social care packages and all
of whom had two or more long term conditions. Table 1 below
summarises the characteristics of our 106 people.
Characteristic Number %
Mortality 19 18
Female 64 60
Male 42 40
Age: 54-65 4 4
Age: 6574 12 11
Age: 7584 43 41
Age: 85+ 47 44
Social care users 30 27
.(:%" ;< 8/(+()4"+9,49), #= 0"12*(3 )#/#+4
./" 0"12*(3 ($$+#()/
Trough an analysis of international and national best practice,
the team identifed a range of morbidities most receptive to
supporting behaviour changes and reducing clinical demand.
Tis was used as the evidence for a series of local shared care
management plans.
>/(+"6 ?(5(@"A"54 !%(5,
It was imperative that organisations involved in the pathfnder
understood their respective roles and responsibilities, this was
achieved through the development of shared care management
plans. Tey were written with the clinical nurse lead for long term
conditions and brought together best practice with defned roles
and responsibilities for the team. Tere is an agreed overarching
frailty management plan together with specifc plans for each of
the long term conditions identifed; every plan includes a protocol
for clinical escalation.
!"#$%" 1"+" ,"%")4"6
9= 4/"3 /(6 ( /9@/ +9,B #= (
/#,$94(% (6A9,,9#5
!"# %#&' (#)* %"#
+#)*(, &,- %"#.)
/&)#) & +#)*(,&01
/(()-.,&%#- &,- !#2.30#
)#*+(,*#1 4*.,5 %"#
'(*% &++)(+).&%# %#&'
'#'3#) &% %"# ).5"% %.'#
! # 6#(+0#1 60&/#1 64)+(*# 7 !"# 8#9:4&; 6&%"",-#) 6)(<#/%
!"# 8#9:4&; %#&'
Te shared care management plans defne potential interventions
to support a person to become more independent a starting
point for redefning the locality team and the resources that
were likely to be needed. Te locality team was redesigned from
existing resources across Age UK, social care and primary/
community health and with full support from GPs. Te team,
who were co-located but not managed within a single structure,
included a Promoting Independence in People (PIP) key worker
role and trained volunteers managed by Age UK Cornwall
and the Isles of Scilly. Te team ofers
the person and their carer a personal,
coordinated and fexible response, using
the most appropriate team member at the
right time. It starts with a conversation
between the PIP and the person in which
the worker uses motivational coaching techniques, which focus
on the persons aspirations and is designed to build self confdence
and personal resilience. Tis approach actively avoids creating a
new type of dependency on one specifc individual or service.
Te Age UK local team acts as an integrated network pulling in
community, specialist or further clinical expertise where required
and with advice from the social care and community nursing
team. Together the integrated care team works towards achieving
agreed and shared outcomes for
the individual based on the shared
management plans.
!"#$%"& !%()"& !*+$#," - ./" 0"12*(3 !(4/!56"+ !+#7")4 " #
1. mproved wellbeng and qualLy o le
2. nLegraLed workng works
. keduced cosL across Lhe whole sysLem
Te outcomes and performance framework has been developed as
a social impact bond model. Te evidence and lessons learnt from
Newquay Pathfnder are being used to inform Cornwalls Pioneer
programme over the next fve years.
8*4)#9" 85" - :9$+#;"6 <"%%=">5?
(56 @*(%>43 #A B>A"
Our frst outcome is to understand whether the Newquay
approach improves peoples health, wellbeing and quality of life.
To measure this we used the Short Warwick-Edinburgh Mental
Wellbeing Scale (SWEMWBS).
SWEMWBS comprises of a series of seven simple questions. Te
process is designed to be simple to undertake and Questionnaire
1 is completed at the frst visit with the second questionnaire
completed afer six weeks on the programme. Te question set is
fxed for both.
Our analysis shows that the populations self reported wellbeing
improved by 23% against an average improvement locally of 8%-
11%.
C*>%6>5? D#)>(% E($>4(%
We were also interested to see if the Newquay approach impacted
on whether people were able to actively support others in
their community or peer group and thus increase our chain of
wellbeing. In order to do this we monitored the percentage of our
population who were providing community/peer support at the
start of the Pathfnder and again at the end.
We found that prior to the Pathfnder, 0% of our population were
providing community/peer support to others. Twelve months
afer being on the Pathfnder, 10% are providing this support.
F>6 1" 6"%>;"+ #*+ #*4)#9",G
The Newquay PaLh!nder programme was esLablshed Lo LesL wheLher
we could delver Lhree ouLcomes.
8*4)#9" .1# - :54"?+(4"6 <#+H>5?
<#+H,
Tis outcome focuses on the practitioners working as part of the
integrated multidisciplinary team. Without the people who work
in the system and who are prepared to challenge and change the
way they work, we could not have piloted the Newquay approach.
Te Newquay locality team integrates volunteers, district nurses,
community matrons, GPs, voluntary sector staf, local social
workers and case coordinators. Te team are co-located in a
single building and created their own team charter and role
defnitions. Tey have multidisciplinary team meetings.
Te key measurement tool used has been a locally designed staf
survey which looked at a range of questions. At the end of the
pilot 87% of practitioners felt that their work on the Newquay
pilot was very or extremely meaningful. 87% of practitioners
also said that integration was working very well or extremely
well.
8=,"+;(4>#5, A+#9 4/" %#)(%>43 4"(9
Feedback from one of the team leaders observed increased morale
as they feel more supported with other options for signposting.
Practitioners feel there are better step up and step down processes
and an improved range of services to ofer instead of just
discharging a person. Te team is operating as a truly integrated
team with volunteer workers an intrinsic part of multidisciplinary
case meetings and social events.
A key fnding is the importance of trust to the efective working
of an integrated team. Trust to discuss sensitive issues and work
together to fnd solutions, trust to hand work over to volunteers
and trust that volunteers will hand work back when appropriate,
with respect for each others expertise and contribution. In
particular, volunteers are regarded as full members of the team
they are recruited, trained and work to a specifcation in the
same way as paid staf, the diference being they give their time
freely. Tis team ethos needs to be continually nurtured and
commitment to a diferent way of working reinforced.
!" $ !"#$%"& !%()"& !*+$#," - ./" 0"12*(3 !(4/!56"+ !+#7")4
8*4)#9" ./+"" : ;"6*)"6 )#,4
()+#,, 4/" 1/#%" ,3,4"9
Our experience in Cornwall when weve tried to implement
integrated or joined up service delivery, is that there are
unexpected cost and activity impacts on other parts of the system.
In the current fnancial climate where both the NHS and social
care are experiencing reductions in funding, it was important
to know if the Newquay approach was costing the system less
overall. In addition, if it was costing less, was there a cost impact
on other parts of the system in order that both commissioners and
providers can make future decisions? We also wanted to ensure
as far as possible we were able to attribute any impacts to the
Newquay approach and not to other interventions in the system.
<#,4 #= 5#5>"%")4?@" ()*4" (69?,,?#5,
We explored two methods of analysis:
1. Counterfactual modelling using a comparator population
2. Historical cost modelling
Using the counterfactual approach we can demonstrate a 30% for
non elective emergency admissions. Long term conditions non
elective emergency admissions were reduced by 40%.
We developed historic cost modelling using two diferent
scenarios. Scenario 1 was to measure pre-pathfnder days back to
the point of frst hospital admission for the people with long term
conditions and here we can demonstrate a 56% reduction.
Scenario 2 was to look back a further twelve months from the
point of frst hospital admission and here we can demonstrate a
25% reduction.
<#,4 (56 5*9A"+ #= )#99*5?43 ()4?@?43
Analysis of community health cost and activity shows a cost
neutral position. However there has been a shif in case load
management between district nurses and community matrons
due to a change in staf capacity and a community matron
vacancy.
<#,4 (56 5*9A"+ #= (6*%4 ,#)?(% )(+"
$()B(C",
Adult social care costs represent a signifcant proportion of the
whole system public service cost for over 65s in Cornwall.
Using counterfactual modelling we can demonstrate a 5.7%
reduction in the cost of ongoing social care packages in our
pathfnder cohort. What is even more interesting is the reduction
in the rate of new packages of social care.
<#5)%*,?#5,
Te Newquay Pathfnder programme has clearly
demonstrated that by working with people to
understand their aspirations we can:
Improve peoples own feeling of wellbeing
Improve practitioners morale and the
ef ciency of the team and
Reduce costs across the system
Te challenge for our next stage on the journey
in Penwith Pioneer, is to be able to identify
and demonstrate cashable cost reductions
that can result in changes to how services are
commissioned and provided in Cornwall.
!"#$%"& !%()"& !*+$#," - ./" 0"12*(3 !(4/!56"+ !+#7")4 " ##
8",,#5, 8"(+54
9/(4 9#+:"6 9"%%
The mporLance o LrusL - spendng Lme engagng
and buldng Lhe mulLdscplnary Leam as well as
sharng learnng and usng normal socal evenLs
s vLal Lo ensure eecLve workng and case
managemenL
The power o language - creaLng a new
language Lo overcome organsaLonal and
culLural boundares - we Lalk abouL people and
pracLLoners, noL paLenLs and proessonals.
keal people's sLores - Lo demonsLraLe Lhe mpacL
whch sLops Lhe ocus beng all abouL Lhe money
Empowerng ronLlne pracLLoners - Lo redesgn
servces around Lhe ndvdual, puLLng people
!rsL
Fndng Lhe poneers - work wLh people who are
nLeresLed and passonaLe n wanLng Lo change
Lhe sysLem, noL necessarly Lhose n charge
Focus on whaL people can do - LreaLng people as
acLve parLcpanLs, noL passve recpenLs o care
Developng shared ouLcomes and measures -
shared passon, commLmenL Lo !ndng soluLons
and posLve challenge
Changng Lves - havng a shared vson o Lhe
uLure across Lhe publc and volunLary secLors
;")#<<"56(4=#5,
We know we can make a derence Lo 1OO
people, we need Lo LesL Lhs approach wLh
a larger cohorL across a large geographcal
area
We musL conLnue Lo develop Lhe model
and LesL Lhs wLh oLher populaLon groups
n Cornwall ocusng on a whole personi
whole le approach
Leaders need Lo undersLand and accepL
LhaL LransormaLonal change s complex,
messy and doesn'L !L neaLly nLo a projecL
box
We musL conLnue Lo challenge
organsaLonal and naLonal process and
bureaucracy
nvolvng all levels o organsaLons n Lhe
change - ownershp or Lhe change needs
Lo be wLh pracLLoners, mddle managers
and sLraLegc leaders
hgree a meLhodology or cosLibene!L daLa
analyss up ronL and de!ne an evaluaLon
ramework aL Lhe sLarL
Use normaLon governance as an enabler
noL a blocker
denLy nnovaLors aL all levels n
organsaLons, engage Lher passon and
use Lhs Lo creaLe susLanable change
!" $%& '%&() (*+, "&-./,- *0"%-12.*%0
%0 ./, 3,'4&2$ 52./!0),- 5-%6,7.
8(,29, 7%0.27.:::
;-27,$ <%%9,
!"#$ &'( )* !+,-./00 1 230(3 +4 567008
(9/70: ;,/6 (8</'(=>6+,-./00?+,'?=>