Shropshire Transforming Care Partnership Footprint
Transforming Care Partnership (TCP)
Shropshire Transforming Care Partnership (TCP) is working together across health and social care to provide coordinated services for people with learning disabilities and autism, with behaviours that may challenge. Over the next three years we will be working with individuals and their families to develop plans to support them in their own communities.
Where possible we want to support people in their own homes and prevent hospital admissions. We will promote choice and independence by developing alternative housing options and providing people with their own budgets to buy their care if they want to. By developing new ways of supporting people we intend to reduce the number of people with learning disabilities and autism, with behaviours that may challenge in hospitals by 50% by 2019.
The four organisations within the Transforming Care Partnership (Shropshire CCG, Telford and Wrekin CCG, Shropshire Council and Telford and Wrekin Council) are delivering against the plan and committed to the principals of ‘Building the Right Support and Service Model.
A copy of the plan can be found here Transforming Care Planning Shropshire Final.pdf [pdf] 2MB
Please note the plan has not yet been signed off by the respective boards’ of each organisation.
An easy read version highlighting the principles of the Transforming Care programme can be found here Easy read Transforming Care work.pdf [pdf] 915KB
GP resources to support Annual Health Checks
- Health Equality Framework - An outcomes framework based on the determinants of health inequalities https://www.ndti.org.uk/uploads/files/The_Health_Equality_Framework.pdf
- Annual Health Check - new resources: Mencap and NHS England have worked together to produce two videos and a series of guides called Don’t Miss Out to encourage people with a learning disability to check that their disability status is captured on their GP record. A number of resources are available – please visit http://www.mencap.org.uk/dontmissout
- Annual Health Checks for people with a learning disability - step by step toolkit from the RCGP and NHS England to help GPs and practice nurses make sure that people with a learning disability get timely access to the healthcare they need – please visit http://www.rcgp.org.uk/clinical-and-research/toolkits/health-check-toolkit.aspx
- Better health for people with a learning disability: what social care staff need to know about GP learning disability registers, Annual Health Checks and the Summary Care Record. Please visit https://www.ndti.org.uk/resources/publications/better-health-for-people-with-learning-disabilities
- Another way to help patients with a learning disability is by asking for their consent to add Additional Information to their Summary Care Record (SCR AI). This will help improve quality of care for patients when and if they are treated by other services, including emergency and urgent care. SCR AI uses existing information already recorded in the GP system and therefore helps to reduce the need for data entry into numerous systems. Summary Care Records http://webarchive.nationalarchives.gov.uk/20160921135209/http://systems.digital.nhs.uk/scr/additional
- The SEND local offer - Shropshire’s local offer helps families, children, young people and professionals to support those with special educational needs or disabilities to find accurate and appropriate information so that they can make positive decisions about their lives. Please visit https://new.shropshire.gov.uk/the-send-local-offer/
- Improving End of Life Care - End of life care is care that affects us all, at all ages; the living, the dying and the bereaved. For more information please visit https://www.england.nhs.uk/ourwork/ltc-op-eolc/improving-eolc/
- Annual Health Check Audit Tool - For more information please visit https://www.networks.nhs.uk/news/quality-checking-health-checks-for-people-with-learning-disabilities
Common Syndromes associated with learning disability
- Ref number 1: CCG HEF Guidance
- Ref number 2: Downs Syndrome: link to https://www.downs-syndrome.org.uk/for-professionals/health-medical/ for further information
- Ref number 3: Prader Willi Syndrome: link to https://patient.info/doctor/prader-willi-syndrome-pro for further information
- Ref number 4: Angelman syndrome: https://rarediseases.org/rare-diseases/angelman-syndrome/ for further information
- Ref number 5: Autism Spectrum syndrome: http://www.autism.org.uk/professionals/health-workers/guidance.aspx for further information
- Ref number 6: Cornelia De Lange Syndrome: https://rarediseases.org/rare-diseases/cornelia-de-lange-syndrome/ for further information
- Ref number 7: Fragile x Syndrome: https://patient.info/doctor/fragile-x-syndrome for further information
- Ref number 8: Klinefelters syndrome: https://patient.info/doctor/klinefelters-syndrome-pro for further information
- Ref number 9: Neurofibromatosis: https://patient.info/doctor/neurofibromatosis-pro for further information
- Ref number 10: Noonan Syndrome: https://rarediseases.org/rare-diseases/noonan-syndrome/ for further information
- Ref number 11: Tuberous Sclerosis: https://rarediseases.org/rare-diseases/tuberous-sclerosis/ for further information
- Ref number 12: Turners syndrome: https://patient.info/doctor/turner-syndrome-pro for further information
- Ref number 13: Rett Syndrome: http://www.nhs.uk/conditions/rett-syndrome/Pages/Introduction.aspx for further information
- Ref number 14: Velocardio Facial Syndrome: https://rarediseases.info.nih.gov/diseases/10299/22q112-deletion-syndrome for further information
- Ref number 11: Williams Syndrome: https://williams-syndrome.org/doctor/medical-resources for further information
Frequently Asked Questions
1 )What is the Transforming Care Partnership (TCP)
Transforming Care is all about making things better for people who have a learning disability and/or autism that sometimes have behaviour which can challenge. It is about children, young people and adults. Listening to what people and family carers is really important.
After the abuse at Winterbourne View Assessment and Treatment Unit there has been lots of work to support people with a learning disability and/or autism who display behaviour that challenges, to move out of specialist hospitals and live back, nearer their homes.
There are still people living in hospitals, and his has got to change. Lots more people will be moving back to live in the community, which is good for people.
Locally, Shropshire Council, Shropshire Clinical Commissioning Group, Telford and Wrekin Council and Telford and Wrekin Clinical Commissioning Group are working together to develop a plan to help get Shropshire people back living in Shropshire.
In the meantime we are making sure that we keep up to date with the care of people who are placed out of area in order to plan for their return and to ensure they are safe.
2) What does it aim to do?
The local TCP has three key aims:
- Have good services in the local community so people don’t need to go into hospital in the first place
- Bring back people who currently are in hospital to live at home
- Make sure people feel safe and secure in their local community
3) How will it do this?
The local TCP will work with NHS England – which also currently buys care for people who have a learning disability and/or autism that sometimes have behaviour which can challenge, to reduce the number of out-of-area placements.
Over a period of three years (until 2019 initially) the TCP will look to reduce the number of patients within an inpatient (hospital) setting from the current numbers 29 down to 14. This means that Shropshire and Telford and Wrekin CCGs will have to provide services in a community setting for an additional 15 patients.
Whilst the local TCP is absolutely committed to making sure as many of the 29 identified people can come back to Shropshire to live in their local communities, the four organisations of the TCP has not yet fully signed-off the three-year plan. We need to make sure that the services are right and the money is available to support the people coming back, until this financial analysis work has been finalised, the plan remains not signed-off.
4) What are the timescales for implementing the plan?
The plan has been developed during 2016/17 and will aim to deliver its key objectives by 2019. Although, when this initial plan has been implemented, the work does not stop. It will then carry on to make sure that people continue to get the best possible care in the right place and at the right time.
5) What are the risks associated with the TCP?
Shropshire (including Telford and Wrekin) does not have any secure community-based premises for people who have a learning disability and/or autism that sometimes have behaviour which can challenge.
Also, in order to provide the best possible care for people returning back to Shropshire, person-centred care packages need to be developed by the specialist ‘complex care teams’ at the CCGs. This is likely to be a considerable increase in work for an already very stretched team.
6) How are you working to mitigate these risks?
Firstly, the TCP has asked for funding for one of two options regarding premises in the county, which would help provide a solution to this initial problem:
- The first, to build new premises to accommodate12 people returning from in-patient beds
- The second, is to support refurbishment of a building used to provide respite/assessment and treatment reviews
The TCP is waiting to see if either of these options is accepted.