3.5 Priority 5 - Improve support for people living with life-long conditions, long-term health conditions, physical disabilities, and their families

Executive Champion

Matthew Coats, Chair, South and West Herts Health and Care Partnership

Strategic Lead Officers

Lisa Mullins, Hertfordshire County Council
Ruth Harrington, Essex County Council
Sam Williamson, Hertfordshire and West Essex ICB

Priorities

We will support people living with lifelong conditions, long term health conditions, physical disabilities and their families assisting them to take more control of their health and live a good quality of life. We will seek to achieve the following outcomes:

What we will do

Incorporate the following into the Programme plans of the LTC Programme:

Develop integrated community-based models of care that support people with long term conditions to live at home with proactive support and management and reduces the risk of unplanned and emergency
Map existing services and provisions for people with long term conditions
Review information on the health needs of people with long term conditions and the evidence of best practice to develop integrated models of care.
Co-develop integrated models of care through ICS senior advisory groups.

Area of work

Hertfordshire and West Essex

Who will lead?

HWE Long-term Conditions Programme

Timescale

2023/2024

Mapping of heart failure and diabetes services.

2024/2025

Mapping of respiratory services and best practice.
Implement integrated models of care for diabetes and heart failure.

Governance

ICS LTC Board

What we will do

Embed social prescribing, self-management plans and personal goals into the proactive management/annual reviews for people with long term conditions.

Area of work

Hertfordshire and West Essex

Who will lead?

HWE Long-term Conditions Programme

Timescale

2023/2024

Diabetes, COPD, heart failure

Governance

ICS LTC Board

What we will do

Integrate support from wider system partners into care models for people with a long term conditions, maximising community assets. Improve integrated working between health and social care services to provide effective and joined up support to people living with a long-term condition or physical disability through:

Support the identification of touchpoints and handoffs between services and explore additional opportunities for integrated working with wider system partners including other statutory organisations and the voluntary and charitable sector.

Area of work

Hertfordshire and West Essex

Who will lead?

To be confirmed

Timescale

To be confirmed

Governance

ICS Health Creation Strategy

What we will do

Work with partners across the ICS system to provide an integrated, holistic, person-centred approach to supporting young people and their families before, during and after transition between children and adult services
Evidence of local arrangements to ensure compliance with The NICE quality standards Transition from children’s to adults’ services Overview | Transition from children’s to adults’ services | Quality standards | NICE
To embed local arrangements to ensure that a consistent package of support is provided during the years before and after the transition to adulthood include clear process for provision of SEN/ECHP throughout transition and beyond (thinking out ongoing educational input)
Development of a standard operating procedure for transition process, with clear understanding of roles and responsibilities and including communications strategy to keep the young person and their family well informed.
Agreed timescales for when checklists should be started (17) and handover timescales.
Clear definition of what a transition case is, shared agreement between ICB and LA.
Review procedures and processes implemented in other local areas and explore how these can be tailored to suit the needs of residents.
Ensure transitioning between services does not disadvantage individuals through services or types of support becoming inaccessible (i.e. equipment provision).

Area of work

Hertfordshire and West Essex

Who will lead?

Lisa Mullin, Herts
Ruth Harrington, west Essex

Timescale

Years 1 – 2 (2023/24-2024/25)

Governance

Integrated Complex Care Oversight Group (Herts)
ICB Children and Young People Transformation Programme Board (Herts and West Essex)
Preparing for Adulthood Board (Herts)

What we will do

Adopt and expand the Connected Lives model to identify social care needs and meet these needs through prevention, enablement, choice and support in Hertfordshire and a focus on choice, control and independence in Essex.

Area of work

Hertfordshire and West Essex

Who will lead?

Herts and West Essex ICB

Timescale

Years 1 – 2 (2023/24-2024/25)

Governance

HCC and ECC Physical Disabilities Governance

What we will do

Develop a series of communication and engagement events to improve staff awareness and relationships between services.

Area of work

Hertfordshire and West Essex

Who will lead?

Herts and West Essex ICB
Hertfordshire County Council
Essex County Council
VCFSE Alliance

Timescale

Years 1 – 2 (2023/24-2024/25)

Governance

HCC and ECC Physical Disabilities Governance

What we will do

Use findings from mapping to improve communication about work being done in the disability and life-long condition area, across all workforces to build shared ownership and understanding through the use of e.g. newsletter, seminars, promotions.

Area of work

Hertfordshire and West Essex

Who will lead?

Hertfordshire County Council
Essex County Council

Timescale

Years 1 – 2 (2023/24-2024/25)

Governance

HCC and ECC Physical Disabilities Governance

What we will do

Map VCFSE work in this area to understand what ‘local change agents’ are already operating.

Use findings from mapping to inform next steps.

Area of work

Hertfordshire and West Essex

Who will lead?

VCFSE Alliance

Timescale

Year 1 (2023/24)

Governance

VCFSE Alliance

What we will do

Work towards equity of access for people with sensory needs by:

Identify and record preferred means of communication and provide reasonable adjustments for people with learning disabilities
Improve collaboration between colleagues in Health, Social care and Education to ensure services are accessible in line with the NHS Accessible Information Standard

Area of work

Hertfordshire and West Essex

Who will lead?

Hertfordshire and West Essex
Integrated Care Board Mental Health and Learning Disabilities Team

Timescale

Year 1 (2023/24)

Governance

Hertfordshire Sensory Needs Strategy Group and Essex equivalent

What we will do

Map current neurological services and review against national guidance and best practice.

Area of work

Hertfordshire and West Essex

Who will lead?

HWE Long Term Conditions Programme

Timescale

2023/2024: Phase 1 – Core NHS services
2024/2025: Phase 2 – Hospice/Palliative care, CYP transition

Governance

ICS LTC Board

Outcomes we want to achieve for our residents through delivering this priority expressed as “I” statements

As a resident:

I feel supported to manage my long-term health condition or disability myself.
I feel the services required to support my long-term health condition or disability are joined-up.
I understand my condition, feel in control of my care, and know where to go for help and can access support when I need it.
I can care for my own health as well as the person that I care for.
I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes that are important to me.

Potential key performance measures

Indicator 1 – Reduction in the rate of emergency hospital admissions, including readmissions for our older population.
Indicator 2 – Increased number of carers having a carer assessment and receiving appropriate support.
Indicator 3 – Reduction in the percentage of older people reporting that they feel lonely and diagnosed with depression.
Indicator 4 – Increased earlier diagnosis of dementia.
Indicator 5 – Increase in the number of people with LD who die in their preferred place of death (PPD)
Indicator 6 – Increased use of assistive technology to support our residents’ independence.
Indicator 7 – Increased early identification of people in the last 12 months of their life with appropriate end of life support in place.
Indicator 8 – Reduction in the number of people in the last 12 months of their life experiencing crisis A&E attendance.