Suffolk & North East Essex Integrated Care System

Giving people more control & personalised care

WHY this is important for people in Suffolk and North East Essex

Choice and control over our own health and care are essential if everyone in Suffolk and North East Essex is to live well.

As an Integrated Care System we will ensure that:
  • People are able to manage their own health and wellbeing
  • People have maximum choice and control over their health and wellbeing care and support
  • People have expert support to make the care decisions that are right for them
What’s the current picture?
    Research has indicated that personal budgets impact positively on well-being, increasing choice and control, reducing cost implications and improving outcomes. Studies have shown that direct payments increase satisfaction with services and are the purest form of personalisation. The Care Act places personal budgets on a statutory footing as part of the care and support plan.
    Percentage of People ages 65 and over using social care, that receive self-directed support and those receiving direct payments

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Giving people access
What do we know about people’s local experiences?
  • We should encourage personal responsibility in self-care and maintaining own health, and promote healthier lifestyles, screening and health checks.
  • Technology is useful in supporting people; professionals could promote apps to help with self-care, but older people lack of awareness about assistive technology.
  • We should improve awareness of personal budgets and facilitate personalised support.
  • The person must be put first. Professionals should treat people with respect and dignity, be caring, value their opinions, believe the patient, and give people enough time. Health professionals must acknowledge that the patient or their carer are often the expert in their condition and involve them in care planning.

For more information see www.healthwatchessex.org.uk and www.healthwatchsuffolk.org.uk

National Voices’ Narrative for Person-Centred Co-ordinated Care 

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HOW we plan to make a difference 

    1.1 People have the advice and support they need to self-manage their health and wellbeing. We will enable this by:

  • More support for people to manage their own health, starting with diabetes prevention and management, asthma and respiratory conditions, maternity and parenting support, and online therapies for common mental health problems. Advice and support will be available in a variety of formats including high quality digital and online resources to help people become health literate and to choose how they want to self-care. The approach will ensure equality of access for everyone to be able to self-care. When people are supported to become more activated to look after their own health, they benefit from better health outcomes, improved experiences of care and fewer unplanned care admissions.
  • Proactive case finding and support to self-care in primary care. GPs will proactively case-find people, and offer access to support such as health coaching, peer support and self-management education. This will help people to live well with their conditions.
  • People are supported to develop good health literacy.
  • Patient activation is supported and encouraged.

    1.2 People have support from their communities to selfcare.

  • Community-based groups, and primary care resources such as pharmacists, will advise and motivate people to self-care. Communities play an important part in proactive self-care. 1.3 Carers are supported in their role
  • Carers will be involved in helping people to selfcare, and to look after their own health and wellbeing. Supporting carers to help the cared-for person and themselves improves quality of life for both, and helps prevent ill-health. Support for carers will be co-produced with them and include access to a range of services including respite.

    2.1 People’s care and support is based on what matters to them and their individual strengths and needs. We will enable this by:

  • Rolling out the NHS Comprehensive Model of Personalised Care programme. Integrated personalised care gives people the same choice and control over their mental and physical health and wellbeing that they expect in every other part of their lives. Effective models include Signs of Safety, which are already in place in some areas.
  • Focusing care and support on maximising people’s opportunities for good health and independence. Reablement approaches support people to maintain and improve their quality of life.

    2.2 People’s records are made and shared using best practice.

  • People and clinicians will make care records together, and agree the sharing of records with others involved in their care. Agreeing the sharing of records enables people to have control over their data.
  • People will be able to access and have direct input into their own records. Shared recordings and patients adding their own information helps ensure accuracy, and ensures that the person’s voice is heard.

    2.3 People can make decisions about their care based on evidence.

  • We will use tools and evidence that demonstrate to people the effectiveness of specific care and treatments. This helps people to make informed decisions about their care. This should include use of digital technologies.

    2.4 People with long term conditions and disabilities have more choice and control over how the funds for their health and wellbeing are spent. We will enable this by

  • Accelerating roll-out of Personal Health Budgets, including provision of bespoke wheelchairs, community-based packages of personal and domestic support, mental health and learning disability services, social care support and specialist end of life care. Collaborative care planning and agreement between the individual/representative and the CCG about how the funding for their health and wellbeing need will be met, is a different approach to spending money which transfers choice and control to the person being cared for.
  • Encouraging the uptake of personal budgets and direct payments in social care, and the uptake of integrated personal budgets. Personalised care and support planning is key to this approach. Everyone in health and care has a role in encouraging people to take control over their care in this way.
  • Using public health management approaches to identify groups wherever uptake of personal budgets is low. Targeting specific groups and communities can be an effective way to improve uptake of personal budgets.
  • Actively involving carers in decision-making with the person’s agreement. Involvement of carers in decision-making helps ensure plans and service delivery is effective and meets their needs too.

    2.5 People with the most complex needs have intensive personalised support.

  • We will develop Integrated Personal Commissioning for those with the most complex health and care needs. IPC will support the 5% of people with the highest needs, to improve their choice and control over their care, improve quality of life and reduce needs for unplanned care.

    2.6 People can access support for their health and wellbeing within their local communities.

  • Social prescribing link workers in Primary Care Networks will work with people to develop tailored plans and connect them with local groups and support services. Social prescribing can result in improved quality of life and wellbeing; and reduce demand on statutory health and care services.
  • People will be better informed about local groups and communities. Accurate and updated information enables people to access support independently, not solely when ‘prescribed’.

    3.1 People will have the support they need to make the decisions about their care and support that are right for them.

  • Health and care staff will be trained to help patients make informed choices and decisions. Since individuals’ values and preferences differ, ensuring choice and sharing control can meaningfully improve care outcomes. Creating genuine partnerships requires professionals to work differently, as well as a systematic approach to engaging patients in decisions about their health and wellbeing. All those in health and care should be involved in supporting informed decision making.
  • People who need extra support to make and communicate their choices will have support to make decisions. Approaches based on what is important to the person can help ensure those who need extra support to make decisions have their voices heard fully

We will know we are making a difference because we will see:

  • Greater proportion of people who use services who say they have control over their daily life
  • An Increase in active personalised care and support plans from an estimated 323 in 2019/20 to 17,476 in 2023/24
  • An Increase in the number of personal health budgets in place, from 308 in 2018/19 to 3,300 in 2023/24
  • An Increase in the number of social prescribing link workers from 0 in 2018/19 to 41 in 20123/24
  • An Increase in the number of referrals into social prescribing link workers from 1,668 in 2018/19 to 15,881 in 20123/24
  • Greater proportion of people who use services who say they have control over their daily life
  • More people with personalised care and support planning, self-directed support, direct payments

West Suffolk Council brought together statutory services and the voluntary and community sector to discuss how we collectively tackle social issues that affect people’s mood which can limit life experiences, affect wellbeing or cause excessive use of health services. After multi-service discussions, LifeLink was devised as West Suffolk’s response; a way to ‘join the dots’, increasing access to local opportunities, by building optimism, confidence and resilience. Growing the provision through stakeholder and community consultation, and securing a steering group made up of local representatives has been key to our success in developing community ownership, integration and support.

As a collaborative project, led by West Suffolk Council, stakeholders included the CCG, GP practices, One Haverhill Partnership, Job Centre Plus, and other organisations. This enabled the project to meet diverse needs across sectors, identify gaps, share best practice and reduce duplication.

After a 2 year pilot, Haverhill LifeLink demonstrated a significant improvement in wellbeing as well as notable reduction of GP appointments by those who participated. Since then, Brandon LifeLink and Mildenhall LifeLink have been established using a similar model.

Using Health Coaching 1:1 conversations, the LifeLink Coordinators help individuals to develop ownership, and become more proactive in identifying things which could improve their own wellbeing. Throughout, support and practical advice is provided. A LifeLink Drop In Café (monthly) provides a safe place for initial contact, for making new friends, accessing information, and maintaining contact after discharge.

As a project, self-evaluation and ongoing consultation are central. Thinking flexibly, we have been able to make imaginative use of resources and opportunities. Adaptation and change are expected as part of the process, opportunities to work more effectively are actively sought and new partnerships are embraced.

West Suffolk Council brought together statutory services and the voluntary and community sector, including the CCG, GP practices, One Haverhill Partnership and Job Centre Plus, to discuss how we collectively tackle social issues that affect people’s mood which can limit life experiences, affect wellbeing or cause excessive use of health services.

LifeLink was devised, to increase access to local opportunities by building optimism, confidence and resilience. Stakeholder and community consultation, and a steering group made up of local representatives has been key to developing local ownership, integration and support. Using Health Coaching 1:1 conversations, LifeLink Coordinators help people to become more proactive in identifying ways to improve their own wellbeing. Support and practical advice is also provided. A LifeLink Drop In Café provides a safe place for initial contact and ongoing, for making new friends, and accessing information.

After a 2-year pilot, Haverhill LifeLink demonstrated a significant improvement in wellbeing as well as notable reduction of GP appointments by those who participated. Since then, we have established Brandon LifeLink and Mildenhall LifeLink. Self-evaluation and ongoing consultation are central to the project. By thinking flexibly, we have been able to make imaginative use of resources and opportunities. Adaptation and change are expected as part of the process, opportunities to work more effectively are actively sought and new partnerships are embraced.

Dave is 70 years old, and house bound due to a neurological disorder that greatly affects his mobility. Sadly earlier this year Dave’s beloved wife and carer Pat died. One of the many things that Pat did for Dave was take his repeat prescription orders into the doctors so that he could get his regular medication. Whilst Dave has other family and friends who were always happy to help out, he did not want to have to rely on other people.

Earlier this year, the NHS App was launched, allowing patients to check symptoms, view their medial record, order prescriptions online and book appointments. Dave was introduced to the NHS App by a family friend, who helped him register to access the service. This was an easy process that involved entering some personal information and recording a short video to validate who Dave was, allowing the NHS App to link to his personal health record. Within 5 minutes Dave had learnt to navigate round the easy to use NHS App, and had ordered his first repeat prescription, this all happened on a Sunday evening. On Tuesday morning Dave’s medication was delivered to the front door because as well as being able to order his prescription digitally, Dave had his nominated pharmacy selected, so the prescription was sent direct to the local pharmacy and then delivered to home. Dave now uses the NHS App with ease on a regular basis.

Dave says “The new NHS App has given me back my independence and relieved the burden on my family and friends of having to go to my GP Surgery and order my prescription for me. I can now from the comfort of my own home, simply logon when I need to order a prescription, and within a couple of taps on my Ipad, know that my medication will be delivered to the door within a couple of days. I could not recommend it highly enough”

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