In Cheshire, charity Age UK is working in partnership with the NHS and others to improve well being and prevention of ill health by introducing a range of forward-thinking digital initiatives that cross the traditional boundaries of health care and social care.
Here in Cheshire, as the health and care landscape changes, there’s a lot to get to grips with. But there is a real appetite across all sectors locally to work towards building a more system-based approach, and we are working in partnership with healthcare providers to put several programmes in place looking to encourage health services and GPs to use social, not just medical, interventions.
We were in a good position to start with. We already had mature relationships across sectors and organisations and we have drawn on this ‘bank of trust’ to be more collaborative and to test a number of significant changes in how we address deep-rooted problems.
Many of these changes involve looking at how we can blend the use of diverse digital tools into the delivery and co-ordination of more citizen-focused and integrated models that work across systems and sectors.
Cheshire Shared Care Record
For example, we have developed a new single and common thread, the digital Cheshire Shared Care Record, which is currently being piloted in diverse settings and the ambition is to roll it out across our systems. The Shared Care Record contains all the information required by diverse agencies that work alongside citizens. The record has been robustly tested for interoperability and co-designed with citizens and teams from across sectors.
The Shared Care Record will encompass Age UK services. We want to ensure that services provided by the third sector (where they are concerned with integrated ways of working) are part of integrated teams, with the same involvement as the NHS or local government.
Many people locally were involved in previous work to develop a Single Assessment Process, which was based on the recognition that many older people have a range of welfare needs and that agencies need to work together so that assessment and planning are coordinated, care is holistic and information is shared appropriately between health and social care agencies.
This experience has helped to ease those challenging conversations involved in developing the Shared Care Record. It also provided an appreciation of the urgent need to overcome obstacles in getting it right this time.
The local NHS Vanguard (one of 50 NHS organisations selected nationwide to develop new care models to act as the blueprints for the NHS in future) is also helping us to look at demand in primary and social care. This includes recognising that demand:
- can arise as a result of poor service design.
- can be reinforced by service dependence.
- may arise from behaviours that can be changed or influenced.
- often arises from causes that could have been sorted out earlier.
Well being co-ordinators
In West Cheshire we are promoting and supporting community leadership and working across systems to develop a multi-agency community model of care and support. Our GPs now work alongside new ‘well being co-ordinators,’ provided by Age UK Cheshire, who are based in GP practices and in the acute setting.
Well being co-ordinators work with those aged 18 and older, but the predominant cohort is the over 50s. The model blends digital tools with face-to-face contact, co-ordinators are orientated around the community with their main focus on the concerns of the population in that community. They also have access to and real understanding of the local assets that help people to be both independent and interdependent.
This way, they can start to address the root causes that impact on wellbeing, such as loneliness and social isolation. In Cheshire West and Chester alone 21,000 older people often feel lonely and are at risk of social isolation.
With just 10 minutes to spend with patients, GPs and other healthcare workers almost certainly do not have long enough to nake meaningful steps towards getting to the root cause and alleviation of loneliness and social isolation. Some 70% of health outcomes are determined by social factors, and just 30% by clinical interventions.
However, evidence suggests that one of the best forms of prevention and treatment is to empower individuals to get involved in their own community, help them to discover what they can enjoy and rebuild their own social support networks. This is the foundation of ‘Social Prescribing,’ a way for healthcare providers to help lonely and socially isolated patients by referring them into community-based activities so that they improve their own well being.
Through an inter-agency partnership called Brightlife, led by Age UK Cheshire, we are testing the idea of ‘social pharmacies’ and have set up three in West Cheshire and Chester – in Malpass (a village, where the ‘pharmacy’ is located in a fire station), Winsford (a town) and Chester (a city). GPs can refer people to these pharmacies, or they can self refer, and they will be stocked with diverse, cross-sector ‘social products’ that professionals and accessible via ‘prescription.’
The social pharmacy will stock ‘products’ such as exercise on prescription in relation to mental health, recommended local walking groups or the Men in Sheds project, for example.
Men in Sheds has 1200 participants at four locations across Cheshire. Funded privately, any male member of the community, including but not exclusively for those with Dementia, depression or a brain injury, can be referred to a venue by their GP, or through a peer health mentoring scheme where they can go to relax or participate in a number of activities such as carpentry.
All of these initiatives are purposefully ambitious and frequently ask difficult questions of each sector. There is, however, a joint understanding across our local sectors that the goal here is about shifting from the supply-side type of improvements over to the demand and citizen-driven side. We never said it would be easy! It’s all a learning exercise; it’s all about ‘test and learn.’ If it doesn’t work, we fail, close and try again.
About Ken Clemens, FRSA
Ken joined Age UK Cheshire in 2006 as a Policy & Campaigns manager and became CEO in 2011. He previously worked as a policy officer at the European Parliament, spent a number of years with the probation service in London and Brighton, and worked in various roles for Manchester City Council, predominantly in housing and regeneration.