LOCALITY SUMMARIES: September 2017 Appendix B LOCALITY: BURNLEY KEY AREAS OF DISCUSSION & ACTIONS: Burnley Community Health and Wellbeing Partnership Development Burnley Learning Partnership Small Grants Funding Over 75s nursing provision Well Burnley Primary Care Networks Development of the Burnley Community Health & Wellbeing Partnership Dr Santhosh Davis, recently elected Clinical Lead for the Burnley Locality and CCG officers have continued to meet informally with wider partners (East Lancashire Hospitals NHS Trust, Burnley FC in the Community, BPR CVS, Burnley Borough Council, Secondary School head teachers) to further develop the emerging Burnley health and wellbeing partnership, to develop mutual relationships and work closer together to improve long term health outcomes, and deliver a more prosperous, resilient Burnley. To deliver this change we need to work collectively to make better use of the resources we have across health, local government, businesses and the voluntary sector. The first formal meeting has been scheduled for early October and will identify the purpose, shared priority areas and an agreed plan that partners can work together to deliver improved population outcomes for the residents of Burnley. Discussions have taken place with locality practices at both the locality steering group and locality forum to identify priority areas, in particular relating to the provision of mental health services for children and young people within the locality. A scoping exercise is underway to assess the level of support available within the locality for children and young people with mental health problems, referral pathways into services, how wider partners link in and awareness raising of the services available to primary care. Burnley Learning Partnership To further develop the above, Dr Davis and the locality manager met with the five secondary school head teachers in July, in particular to discuss the support available for children and young people with mental health problems. Small Grants Funding The second round of applications has been reviewed and suitable were recommended for approval. Over 75s Nursing Service Provision The over 75s nursing service continues to successfully support all nursing and residential care homes across the locality. Well Burnley The CCG are working with Well North Enterprises CIC in the Burnley Wood area, to find new ways of creating a healthy connected community. Burnley Wood has been identified as an area where there is a wealth of existing relationships, and where there is enduring leadership. Over the last three months CCG Officers have been meeting with key people within the Burnley Wood area who are already making a contribution locally and this work continues.
Primary Care Networks Primary Care Networks (PCN) are collaborations between primary care providers (including community care, general practice, social care, the voluntary sector and others) and provide a population-based model of care to a local population of 30,000 50,000 people based on the registered list of the participating GP practices. Partners develop a multidisciplinary team approach to delivering personalised, holistic care based on the individual s needs rather than disease types. There are three Primary Care Networks within the Burnley locality, to which all practices are agreed to sign up to, in order to create an integrated model of care that works for their local population needs. Dr Santhosh Davis, Clinical Lead Kirsty Slinger, Locality Manager
LOCALITY: HYNDBURN KEY AREAS OF DISCUSSION & ACTIONS: Care Navigation Mental Health Primary Care Networks New Models of Care Hyndburn Community Partnership REAL Directory of Services Care Navigation A large number of Hyndburn practices have now had training on Care Navigation and represent the first cohort of GP Practices in East Lancashire supporting its introduction. Practices have now started to have extended conversations with patients as part of the navigation process and initial feedback is very encouraging. Proposed Primary Care Networks for Hyndburn The GP Practices in Hyndburn and the whole of East Lancashire, have been given the opportunity to form primary care networks. This will involve them working alongside key stakeholder NHS organisations such as East Lancashire Hospital Trust and Lancashire Care Foundation Trust in addition to Lancashire County Council and the voluntary sector. A neighbourhood comprises of around 30,000 to 50,000 registerd patients of which there are two in Hyndburn. However both neighbourhoods will work closely together to explore new ways or working, gain agreement to working as a network, build relationships and complete administrative tasks Hyndburn Community Partnership Discussions are on-going about how Hyndburn should look in the future with a community partnership proposed with the local voluntary sector, council, health and care providers and the police. A workshop is being organised in September to understand the role and function of the Partnership. Mental Health The Social Support Outreach Worker role has been extended until the 31 st March 2017. Discussions are on-going with mental health commissioners around the social support outreach worker and its role in Hyndburn, with a proposal for trialling new ways of working. Including conversations with Community Restart. REAL Directory of Services Hyndburn now has a Directory of Services available to both GP Practices and supporting the Care Navigation initiative referred to above and the general public www.hyndburn.realtd.co.uk. Engagement Continued engagement with member practices and via the Hyndburn patient participation network which is developing a strong patient voice.
LOCALITY: PENDLE KEY AREAS OF DISCUSSION : Locality Specific Pendle Health and Well Being Partnership Group Update ANP in Care Homes Engagement Primary Care Networks Syrian Resettlement Programme Update Pendle Dementia Action Alliance KEY ACTIONS: Pendle Health and Well Being Partnership Group The partnership will meet on a bi-monthly basis and met for the second time in August. Key initiatives to note include: Employment Support Allowance As part of the working relationship with Pendle Borough Council and the Pendle Health and Well Partnership work, Gill Dickson has been in contact with the CCG to see if there are two practices that would work in partnership with Pendle Borough Council (PBC) and Department of Work and Pensions (DWP) to develop a joint employment support initiative for Employment Support Allowance (ESA) claimants. The Council are looking to target Southfield and Waterside wards where there are high ESA claimant rates. The proposal is for the DWP to operate satellite services in the two areas so that when Fit Notes are being considered, direct referrals can be made to DWP work coaches based in the practice. It is envisaged that the DWP colleagues will work closely with the Community Care Navigators to ensure longer term support and sign post to other support services that are available. Up and Active As part of a Lancashire wide initiative, Pendle Up and Active Team is hosting a Health Week to encourage people of all ages to get fitter and healthier. From September 16-24, a full week of free, fun, information and activities have been organised including (but not exhaustive) a family sports day, Tai Chi in the Park, health checks in Health Centres, Weight Management roadshows, walks, healthy eating and school workshops. Primary Care Networks Pendle locality are working to meet the requirements of developing Primary Care Networks across the locality. Both Pendle East and Pendle West have held discussions with regard to meeting the requirements and are keen to work closely together to explore new ways or working, gain agreement to working as a network, build relationships and complete administrative tasks. A meeting has been organised for 21 September to agree prinicples and take the process forward. Engagement Practices within the locality continue to actively engage in numerous forums, schemes and initiatives in line with the CCG Constitution. Patient Partner Representative The locality is seeking expressions of interest for two lay representatives to sit on the Pendle Locality Commissioning Steering Group. We are looking for individuals to contribute to the continuing development of locality working specifically providing the patient voice and acting as conscience locally about patients interests and concerns around access and delivery of healthcare. The aim is to provide a high quality, efficient and user accessible services to patients. Closing date has been extended to 28 September and interviews will follow in due course.
ANP in Care Homes Alex Blake, Advance Nurse Practitioner continues to work with nursing and residential care homes across the locality. Her work portfolio consists of Advanced Care Planning and DNACPR for residents and to embed elements of the Enhanced Health in Care Homes Framework. Syrian Resettlement Programme Working in partnership with the Home Office, Lancashire County Council and Pendle Borough Council; ten families were resettled over the summer into the locality and five families into the Burnley locality. Concerns have been raised with regard to the provision of dental services with appropriate language interpretation present at the time of treatment. Discussions are taking place with LCC and NHS England to come to an appropriate solution for all. Pendle Dementia Action Alliance The Pendle Dementia Action Alliance (DAA) continues to meet on a bi-monthly basis with key partners from across the locality. Memory Walk The group in conjunction with Burnley DAA held a memory walk on 03 September. The 6 mile walk had two separate meeting points (Victoria Pavilion and Kingfisher Marina, Reedley). The Memory Walk was for all ages and abilities and the sponsorship money raised will go to the Alzheimer s society to defeat dementia. Approved By: Dr Asif Garda Clinical Lead - Pendle Cath Coughlan Locality Commissioning Manager
LOCALITY: RIBBLESDALE KEY AREAS OF DISCUSSION: Ribblesdale Community Partnership Public Engagement. One Workforce Children and Young People s Services Frailty Project Age UK End of Life Pilot Personal Health Budget Pilot KEY ACTIONS: Ribblesdale Community Partnership The Ribblesdale Community Partnership is currently implementing its action plan; key areas of development are highlighted below. Memorandum of Understanding A memorandum of understanding has been drafted and agreed between all Providers and will be signed by each member to show commitment to delivering the strategy and action plan of the Ribblesdale Community Partnership. Public and Staff Engagement Engagement exercise has been completed; we have received around 200 responses to the questionnaire. A report is currently being produced and will be presented to the Community Partnership on the 28th September. The feedback will be added to the action plan for implementation. Children and Young People s Services The Children and Young People s needs analysis continues and a project group has been established to support its implementation. Discussions are also underway to look to roll out the Rossendale children and young people s pilot in Ribblesdale, a workshop is being set up to take this forward. Frailty Project Ribblesdale have identified Frailty as a key area for improving health and care, this is based on the data identified within the Ribblesdale Community Partnership strategy and also as it s a health improvement priority for Pennine Lancashire. The main objective of the project is to develop an identification and care pathway for professionals to use to assist in the care management of patients identified as being frail within the local community. This work will include: To proactively identify patients with frailty in the Ribblesdale locality (within each GP practice population). Provide a Multi-disciplinary approach for frail patients care management involving the Integrated Neighbourhood Team MDT reviews, the expertise of clinicians, social care and voluntary sector. With particular focus on admission avoidance care planning, falls assessments, polypharmacy reduction, advance care planning and mental well-being. Training and skills development for primary care clinicians to possibly incorporate as part of a patient s annual review to assess balance and provide a falls risk score. Maintain a high standard of care to patients with frailty in Care and Nursing Homes within the Ribblesdale locality. To ensure that co-ordinated care occurs in a timely and effective manner for the residents with a view to avoid unnecessary hospital admissions. To strengthen collaborative working between practices and the local community services including the falls service.
Audits for Frailty are currently underway in each Practice and a workshop is being held in January 2018 to take the Frailty Project forward. Primary Care Networks Ribblesdale have put developed their application for Primary Care Networks to support their work within the Community Partnership and continue to work at scale. The funding for Primary Care Networks in Ribblesdale will be utilised to progress the heart failure project and the frailty project. Dr Vanessa Warren Kirsty Hamer Clinical Lead - Ribblesdale Locality Commissioning Manager
LOCALITY : ROSSENDALE KEY AREAS OF DISCUSSION: Out of Hospital Care for Children & Young People Rossendale Pilot Proposed Primary Care Networks for Rossendale Progress towards a Rossendale Community Health Partnership KEY ACTIONS (Highlights from the areas listed above): Out of Hospital Care for Children & Young People Rossendale pilot Led by both ELHT and the EU Federation with support from CCG Commissioners this project is now live. One of the principal aims is to provide improved working relationships between primary care, secondary care and wider partners through closer links and multidisciplinary team (MDT) working. Joint MDTs are now taking place every 6 weeks between practitioners that draw up care plans for more complex cases to reduce admissions to secondary care. This will ensure that patients get seen in the most appropriate service and that GPs feel supported to manage care locally with Consultant led clinical expertise. Proposed Primary Care Networks for Rossendale The GP Practices in Rossendale and the whole of East Lancashire, have been given the opportunity to form primary care networks. This will involve them working alongside key stakeholder NHS organisations such as ELHT and LCFT in addition to LCC and the voluntary sector. A neighbourhood comprises of around 30,000 to 50,000 registerd patients of which there are two in Rossendale. However both Rossendale neighbourhoods will work closely together to explore new ways or working, gain agreement to working as a network, build relationships and complete administrative tasks. Progress towards a Rossendale Community Health Partnership The Rossendale locality are progressing towards being a formal community health partnership. This will allow for the development of new collaborations, ways of working, learning and the raising awareness of the role of partners (resource and expertise), A collective focus in joining up existing programmes and projects, plus an early action approach for those at risk or vulnerable. The Community Health Partnership would include, amongst others, representatives from Rossendale Borough Council, Rossendale Leisure Trust, Police and Fire Services and Lancashire County Council, plus other key stakeholders from the voluntary sector. Approved By: Dr Tom Mackenzie Clinical Lead Rossendale Andy Laverty Locality Manager Rossendale