Stakeholder Engagement Workshop Q&As (March 2019)

Shropshire Care Closer to Home has taken on board the feedback and questions we have received and these have formed the basis for the Q&A sheet.

1. How will you know if your plans for Phase 2, Case Management, will work?

We are testing the proposed model by setting up Demonstrator sites in eight areas across the County.

They are across multiple sites to take account of different geographical demographics including the issue of rurality.

2. What are the plans for commissioning Shropshire Care Closer to Home?

Once the phases have gone through the design process they will be tested thoroughly to make sure that the benefits to patients that we envisage are indeed forthcoming.

The new service model will then go through a rigorous procurement process to ensure that those providing it can do so against clear specifications.

3. Who will make up the workforce for Shropshire Care Closer to Home?

Shropshire Care Closer to Home is not just about the NHS – it’s a whole team approach including local authority professionals such as social services, mental health professionals, the voluntary sector, neighbourhood groups and community groups plus of course carers.

The Programme aims to maximise the valuable expertise and experience we already have but to co-ordinate it to reduce duplication and increase efficiency to create a better service for patients.

4. GPs have concerns that they will be expected to take on the medical cover in Phase 3 – who will be providing it?

We can reassure GPs that the work will not fall to them. There is no intention of creating extra work for GPs to take on clinical responsibility in this model.

There will be a ‘stepped-up’ level of care. This will be delivered by the community team but the care would be overseen by a consultant or frailty expert.

Shropshire Care Closer to Home does not create any additional work for General Practices. It actually improves how primary care works by providing GPs with an increased access to a wider range of community services and teams.

5. How does the Hospice at Home Service and Palliative Care fit into Phase 3?

Hospice at Home and palliative care are existing services based in the community and Shropshire Care Closer to Home will work with them to ensure that patients get the care they need and want.

The programme is flexible in that the care provided, whether it be by Hospice at Home or Shropshire Care Closer to Home, serves the needs of the patient best.

The new team will work alongside and with Hospice at Home to ensure that end-of-life requirements are met.

6. Who will help the patient with end-of-life care?

As part of the programme, patients will be monitored so their end-of-life care will be fully supported and that patient choice is upheld. All of which will inform an end-of-life plan.

7. How do you best support a person living with dementia and those with multiple complex needs?

We are developing a team working with Midlands Partnership Foundation Trust (MPFT), which already provides dementia services, and this will form a specialist multi-disciplinary crisis dementia team.

8. What arrangements are there in the system to ensure all organisations work together as one?

Shropshire Care Closer to Home is a system approach bringing together all the health and social care partners. Partnership is already built into the development of the programme and overseen by a partner-wide programme board that reviews the work.

This partnership approach is being further developed in the practical application of any planned models as we work with our partners to build links.

9. How will you ensure that the programme is resourced appropriately?

The NHS, local authorities and community-based organisations have limited resource, we all have a responsibility to ensure that public funds are used appropriately to deliver the best possible care for patients. The programme is about using what resources there are and making them more efficient and effective. It will be a smarter way of working, to make public monies go further, work harder, and achieve more for our patients.

We need to ensure that the right care is in place for the people of Shropshire, not just now but in years to come. Currently far too many resources go into hospital-based care rather than supporting people to live independently at home or near home.

10. As you are describing a major transformation of services – what are you plans for consultation?

Many patients and members of the public in Shropshire have been involved from the outset and will continue to be. This is to mould the future of new services and to ensure the programme is what people need and want.

People will be receiving services in a very different way and we are determined to keep a constant flow of information at every stage of the process.

The majority of Phase 3 is about new services which offer more to patients. It is not losing or cutting services. We will need to review and potentially change the provision of community beds in the county (work has not yet started) and this may require formal consultation.

We shall keep all our stakeholders informed of the developments as they happen and seek views from patients and the public on their experiences of current services and their ideas for future provision.

11. Will one team deliver all elements of the new service being described in phase 3?

Our aim is to ensure that services in phase 3 move seamlessly around the needs of patients unlike the current system. Communication between the teams and services is key and measures are being put in place to implement this. This will enable it to work as one cohesive service even though different organisations might be involved.

We are currently working on how the phases, but it is anticipated that patients will not be aware they are moving between the services.

12. How can we help carers understand their role and how it impacts on Shropshire Care Closer to Home?

Shropshire Care Closer to Home recognises the work of carers in this programme. The Case Manager will work with patients and carers to understand their condition, their medication requirements, and how this best fits in with their daily living.

13. What will be the values and behaviours of the workforce?

Shropshire Care Closer to Home is advocating that home is often best and a patient’s needs are paramount. There needs to be a holistic approach to the health and social care in the community.

14. What happens at the end of a period of care and the only need left is long-term social care?

The patient’s level of care will be assessed by the Case Manager. A social worker is part of the multi-disciplinary team who will be working around the patient and will ensure that long term plans meet the patients ongoing social care needs.

Even if a patient has no further need for ongoing healthcare if social care is required it will be provided as is the case now.

15. Can you confirm that Diagnostic, Assessment and Access to Rehabilitation and Treatment (DAART) provision is available to patients that are under 65 in the new system?

DAART is already currently available for all ages and that will continue. The services available through DAART will be standardised across the county.

16. How will it work with the roles of the Case Manager, the social worker and General Practices?

The Case Manager and community based team, including the social worker, will be working alongside the system providers to ensure all parts of the programme are joined up and wrapped around the patient.

Case Manager

The Case Manager is a pivotal role in co-ordinating the care of patients.

There are many people already in the existing workforce who have the wide-ranging skills for this planned role from various backgrounds, including district nursing and therapy teams. In particular, there are those who have communication and management skills who may like to move across to the Case Manager role. The roles for the programme will be developed in due course.

General Practices

GPs are a vital link for providing information to the Case Manager.

17. How closely are you working with Telford & Wrekin?

Both Telford & Wrekin and Shropshire CCGs are looking at a similar model. These pieces of work need to be aligned and we are working with our colleagues at Telford & Wrekin to co-ordinate our response and plans.

18. How will the assessment of patient risk be managed?

All frontline clinicians be they social care or health care understand the responsibilities that they carry to ensure that patients are looked after properly while respecting patient choice. Clinically-based risk assessment will remain a cornerstone of Shropshire Care Closer to Home.

19. What role will community hospitals play in future plans?

As we move to care in the community, community-based health hubs are more important.

A review of community provision will be required to ensure that its best fulfils the needs of Shropshire patients.

20. Why is the Frailty Intervention Team (Phase 1 of the Programme) hospital based – would it be better to be a community hospital or GP based?

The frailty teams are based in the A&E departments of hospitals as a central frontline location. They are best placed to respond to the needs of patients who are brought into hospital.

This allows the teams to provide a rapid assessment and ensure that the patient is transferred to the most appropriate care setting.

Once the other services (phases 2 and 3) are in place we will see a reduction in admissions to the emergency department because we will be reaching those people earlier in the community. At the moment people go to A&E because there is no alternative.

In the proposed model, services i.e. the frailty team can be relocated to wherever they are needed.