Herefordshire and Worcestershire’s Long Term Plan
Our aims Our Vision: “Local people will live well in a supportive community with joined up care underpinned by specialist expertise and delivered in the best place by the most appropriate people .”
Our core priority areas As well as specific service developments within these 5 priority areas, we also need to think about how we work to keep people well (prevention), how we ensure care is personalised to each individuals needs, and our individual responsibilities around self- care. Our approach to prevention and personalised care is on the next slide.
Prevention and personalised care • Social prescribing within our GP practices • Improving access to advice and information to support people to self-care • New personalised approach to care so people can make decisions on Supporting people to maintain good health their own health and care and wellbeing , as well as helping others to of their long term change some aspects of their lifestyle to conditions improve how they feel and reduce the likelihood of becoming ill. • End of life care planning
Integrated primary and community services We have invested in ‘out of hospital’ teams to ensure hospital stays are as short as possible, and that admissions to a bed are a last resort For the first time we have developed teams across our communities which bring together District Nurses, Therapists, Social Workers and GPs – Neighbourhood Teams These teams work together in a more joined up way to provide more proactive and responsive care to people in their own homes. ➢ Reductions in repeat GP appointments ➢ Reductions in regular avoidable hospital admissions for this group of patients
Improvements in mental health and learning disability services • Identify and manage mental health conditions at an early stage to help The Now We’re Talking prevent crises; campaign has had a • significant impact increasing Parity of esteem, especially for people awareness of Worcestershire with long term conditions; Healthy Minds which is a self- • Improving access to urgent mental health referral service for people services experiencing stress, anxiety or • Recovery focused mental health approach depression. • Reduce health inequalities, such as those experienced by people with a Learning Disability or Autism • Improving access to Perinatal Mental Health services for women during pregnancy and after birth
Urgent Care Elective care Cancer • • • Improving access to out Joined up services across Smoking cessation support of hospital care primary and secondary • care Early detection through • More GP appointments screening • Providing ‘virtual’ • • Proactive care planning outpatient appointments Access to health and for people living with wellbeing events for a • frailty Personalised approach to more holistic approach to elective care services and recovery. • Reducing the reliance on better support to self- bedded care. manage their own conditions.
Our key enablers Workforce – our biggest asset Key to a sustainable and resilient The role of digital service is our ability to retain our • Increased sharing of information between existing workforce and then recruit GPs, hospital colleagues and train new staff. and paramedics • Digital First Primary We are developing a range of new Care for example the roles including Registered Nursing NHS App or Video Associates and Social Prescribers. Consultations. • Clearer signposting to Health and Care Co-ordinated approach to systems we would recruitment to ensure organisations recommend. are managing our workforce as effectively as possible. 8
How we are organising ourselves We recognise the importance of all local health and care providers and commissioners working together to provide the best services we can . • In Herefordshire and Worcestershire local healthcare organisations have been working together in partnership (STP) for some time • Now these relationships are in place we are developing even closer ways of working at a system level (ICS) to ensure patients get the safest, most effective and efficient services when they are needed. 9
Partnership ICS Partnership Board Forum for joint discussions, partnership work & consensus building ICS Executive Leadership Strategic Commissioner Decision Forum making Strategic commissioning/system Executive decision making management decision making and oversight group Clinical ICS Quality Forum ICS Financial Managing the business Leadership System wide quality assurance, overseeing Leadership Forum Forum quality improvement. Implementing new System wide financial recovery and cost Develop and quality framework out/ delivery of system control total deliver clinical strategy ICS System Performance Forum Proactively monitors & reports system performance issues, overseeing performance improvement 16 Overseeing LTP 2 Place Based (County) Provider Alliances: Programmes Delivery PCNs - Acute, community, mental health and associated services Work DAG - Partnership Working with Local Authorities 2 Health and - Redesigning services and pathways to meet population needs and Wellbeing optimise the use of resources Boards 10
How to get involved To keep up-to-date with the latest engagement events and news visit www.yourconversationhw.nhs.uk 11
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