Newsletter - May 2016 - Setting direction with new models of care

Our commitment to creating a radical new approach to local services (known as a Multi-specialty Community Provider or MCP for short) has reached a new phase. Operating under the Stockport Together banner, senior leaders from the key health and care providers have signed an agreement which will see the organisations work together, to a single set of objectives to reshape local care services.

Signing the agreement formalised the plans to come together as a shadow organisation for the care of older people for the next 12 months, ahead of the launch of a new health and care organisation in April 2017.

Under the new way of working, eight neighbourhoods have been identified in Stockport, which will provide health and social care services closer to home. Neighbourhood teams will be expanding over the coming months, to bring together nurses and community health services, hospital specialists and other health and care providers to deliver services within the community. The eight neighbourhoods across Stockport are: Cheadle, Bramhall, Stepping Hill, Victoria, Heatons, Tame Valley, Marple and Werneth.

Bringing providers of care together in this way will bring about a number of benefits for people, including:

  • Reduced hospital referrals and treatment closer to home
  • Improved healthy life expectancy and mortality rates
  • Improved availability of information and advice to help people to manage illness at home
  • A range of ways for people to find support to improve their lifestyles – for example, advice in peoples place of work
  • Reduction in the need to attend hospital for outpatient appointments
  • More support for people with long term conditions in the community

As part of Stockport Together’s vanguard programme all the providers have committed to further developing the eight neighbourhoods across Stockport, so they are in a position to take more responsibility for providing a better range of services at a local level.

At the same time as formalising the ways in which the providers will work together, Stockport Clinical Commissioning Group (the CCG) and Stockport Council are joining forces to start their journey towards the creation of a new commissioning function for health and social care.

April 1st signalled the beginning of a legal agreement between the two organisations to pool together £200m of local budgets.

The CCG and Council will work closely together to commission joined up services in the community that support people to stay well at home. The focus will be on helping people maintain their independence and wellbeing, and providing more dedicated support to manage long term conditions and moving some care out of hospital and into the community.

This work is integral to the Greater Manchester devolution plans under which Greater Manchester partners (including Stockport) take charge of a £6bn health and social care budget.

Update from the workstreams

The new model of care is based on eight neighbourhoods and we have developed four workstreams to help deliver the requirements. These are:

• Working with communities in each neighbourhood to encourage social movement – Healthy Communities:

The healthy communities workstream complements the neighbourhood activity, but has a specific focus on ‘social movement for health’, which seeks to inspire people to take more care of their own health by promoting self-care by giving guidance about this can be done effectively.

For individuals this will be through providing the motivation, skills and confidence needed, as well encouraging the building of networks which will empower people to take control of their own health, this could include families, friends and the wider community.

The healthy communities workstreams is seeking to change how people receive services, in order to help people to help each other. This will be done through tools such as the patient activation tool, which can be used to gauge whether people can be directed to self-help support or whether they need more guidance. Ultimately, through this activity, Stockport Together would like to encourage the public to use other people than just professionals for their health and care support, including expert patients.

• The services delivered within the core neighbourhood at neighbourhood level – Core neighbourhoods:

The core neighbourhoods workstream is focusing on how resources can be delivered at a local level, to find people at risk and help them early. The aim is for people to be able to manage their own support, and to avoid unnecessary referrals into specialist services.

The core neighbourhood model will aim to support people who require multi-agency support, and will bring in providers of non-statutory services as well. The activity will aim to reshape GP services, and will look at alternative professionals delivering some of the services which have traditionally been provided by GPs in order to free up time within practices.

• The borough-wide community based services being better aligned to the needs of the neighbourhood – Borough wide services:

The team has completed a prioritisation exercise, and as a result it has been agreed that the focus will be on the intermediate tier (which includes health and care services offered to patients after being discharged from a hospital and before they’re home. It’s also defined as 'short-term, intensive intervention'.) This was selected as it was felt that it was an area which would provide demonstrable results.

There are currently 20+ services offered in Stockport across health and social care, delivered by different providers. 90% of all activity happening in intermediate tier services are focused on supporting people to leave hospital as soon as possible, but Stockport Together activity aims to avoid people needing to arrive in hospital in the first instance wherever possible.

This activity should have a big impact on ED attendance, and would be looking to create a single point of access for intermediate tier services, which is accessible to all health and social care professionals.

• A more collaborative relationship between hospital and community services including which will include a reduction in the number of hospital based outpatient appointments – Acute specialist interface:

The acute interface workstream will be working with people who have routine appointments – typically those with long-term conditions – and helping to manage peoples’ transition in and out of hospital, through working on the referral pathways.

The goal of this workstream is to make sure people only go to hospital if they need specialist care that cannot be delivered elsewhere. It will seek to identify alternatives, including community services, different use of GP appointments or using technology such as Skype to reduce the need for face-to-face sessions.

The main focus will be on managing people's health where it should be managed in the most appropriate setting, and could include putting things in place that reduces the need for people to have traditional outpatient appointments. This will be done by identifying where the services could safely and appropriately be delivered instead of in a hospital setting.

To find a more detailed description of the four workstreams, please visit:

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