Executive Champion
Sharn Elton, HWE ICB Place Director, East and North Hertfordshire
Strategic Lead Officers
- Helen Maneuf and Cath Fenton, Hertfordshire County Council
- Melanie Williamson, Essex County Council
- Amy Jackson, Hertfordshire and West Essex ICB
Priorities
We will ensure our residents are supported to age healthily, with access to advice and services that enable them to live well and independently for as long as possible. We will seek to achieve the following outcomes:
What we will do
Share learning from hospital activity on deconditioning i.e. ward led enablement pilot at Princess Alexandra Hospital.
Area of work
Hertfordshire and West Essex
Who will lead?
- East and North Herts Health and Care Partnership
- South-West Herts Health and Care Partnership
- West Essex Health and Care Partnership
Timescale
Year 1 (2023/24 – 2024/25)
Governance
ICS Frailty Board
What we will do
Ensure public health campaigns, for example “when did you last go out” include links and signposting to services such as befriending or frailty assessments.
Area of work
Hertfordshire and West Essex
Who will lead?
- Hertfordshire Public Health
- Essex Public Health
Timescale
Year 1 (2023/24 – 2024/25)
Governance
ICS Prevention Strategic Group
What we will do
Produce, share, and promote information to the public regarding simple exercises in the home to prevent deconditioning & highlight the importance of supporting people to remain independent (will become ever more important as more people are cared for at home).
Area of work
Hertfordshire and West Essex
Who will lead?
- Hertfordshire Public Health
- Essex Public Health
Timescale
Years 1 – 2 (2023/24 – 2024/25)
Governance
ICS Frailty Board
What we will do
Work collaboratively with district/borough councils to review accessibility of current green spaces and activity programmes.
Area of work
Hertfordshire and West Essex
Who will lead?
- District and Borough Councils
- Hertfordshire Public Health
- Essex Public Health
Timescale
Years 1 – 2 (2023/24 – 2024/25)
Governance
Sustainable Herts and Essex equivalent
What we will do
Work with partners to secure agreed sustainable recurrent funding and commissioning arrangements to prevent deconditioning (linking with voluntary sector organisations that visit homes and may pick up early signs.
Area of work
Hertfordshire and West Essex
Who will lead?
- Herts and West Essex ICB
- Hertfordshire County Council
- Essex County Council
Timescale
Year 2 (2024/25)
Governance
ICS Frailty Board
What we will do
Work with partners to establish data sharing agreements across Hertfordshire and West Essex geography to support care without multiple referrals (e.g. council lists as to who needs support with putting bins out).
Area of work
Hertfordshire and West Essex
Who will lead?
- Herts and West Essex ICB
- Hertfordshire County Council
- Essex County Council
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
To be confirmed
What we will do
Explore opportunity for digital inclusion and technology through education and digital accessibility in the community through community hubs using VCFSE.
Area of work
Hertfordshire and West Essex
Who will lead?
- Herts and West Essex ICB
- Hertfordshire County Council
- Essex County Council
Timescale
Years 1 – 3 (2023/2024-2025/26)
Governance
ICS Health Creation Strategy Group
What we will do
Work to improve and integrate pathways for early diagnosis and develop public messaging on the early signs of dementia and frailty.
Area of work
Hertfordshire and West Essex
Who will lead?
Herts and West Essex ICB
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
ICS Frailty Board
What we will do
Clarify the pathway for referrals to secondary care/frailty hubs and provide information for care providers and the voluntary sector to improve timely referrals from the third sector.
Area of work
Hertfordshire and West Essex
Who will lead?
- Herts and West Essex ICB
- SW Herts HCP
- EN Herts HCP
- West Essex HCP
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
ICS Frailty Board
What we will do
Consider including early diagnosis for frailty and dementia as part of Health Checks for 40 – 74 year olds within a multi-disciplinary community team approach so that signposting to services can occur at time of health check.
Area of work
Hertfordshire and West Essex
Who will lead?
- HCC Public Health
- ECC Public Health
- Herts and West Essex ICB
Timescale
Years 1 – 3 (2023/2024-2025/26)
Governance
ICS Frailty Board
What we will do
Better position community health checks with services/VCFSE/social prescribers to improve outcomes for residents.
Area of work
Hertfordshire and West Essex
Who will lead?
- HCC Public Health
- ECC Public Health
- Herts and West Essex ICB
Timescale
Years 2 – 3 (2024/2025-2025/26)
Governance
ICS Prevention Group
What we will do
Raise awareness to the public of services that aim to prevent admission to hospital in Hertfordshire and West Essex.
Area of work
Hertfordshire and West Essex
Who will lead?
Herts and West Essex ICB
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
ICS Prevention Group
What we will do
Consider expanding the current number of Dementia Friendly communities and/or explore World Health Organisation ‘Age Friendly Cities, working with district/borough councils. The latter includes an assessment to achieve age friendly status against the following areas:
- Community and healthcare
- Transportation
- Housing
- Social participation
- Outdoor spaces and buildings
- Respect and social inclusion
- Civic participation and employment
- Communication and information
Area of work
Hertfordshire and West Essex
Who will lead?
- District / Borough Councils with Essex Public Health
- ECC Integration and Partnerships
- Hertfordshire Public Health
- West Essex HCP
- SW Herts HCP
- EN Herts HCP
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
Hertfordshire Dementia Steering Group and Essex equivalent
What we will do
Involve residents, especially carers of those with dementia and mild cognitive impairment in the community assessment.
Area of work
Hertfordshire and West Essex
Who will lead?
- District / Borough Councils with Essex Public Health
- ECC Integration and Partnerships
- Hertfordshire Public Health
- West Essex HCP
- SW Herts HCP
- EN Herts HCP
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
Hertfordshire Dementia Steering Group and Essex equivalent
What we will do
Review open spaces / changing spaces accessible toilets and spaces to sit.
Area of work
Hertfordshire and West Essex
Who will lead?
- District / Borough Councils with Essex Public Health
- ECC Integration and Partnerships
- Hertfordshire Public Health
- West Essex HCP
- SW Herts HCP
- EN Herts HCP
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
Hertfordshire Dementia Steering Group and Essex equivalent
What we will do
Seek accreditation as WHO age friendly (or explore what additional work is required to make a more inclusive community for all e.g. needs of children or those with disabilities etc).
Area of work
Hertfordshire and West Essex
Who will lead?
- District / Borough Councils with Essex Public Health
- ECC Integration and Partnerships
- Hertfordshire Public Health
- Essex LEP
- Hertfordshire LEP
Timescale
Years 2 – 3 (2024/2025-2025/26)
Governance
To be confirmed
What we will do
Work with the Local Enterprise Partnership (LEP) to engage with businesses to support communities and outdoor spaces.
Area of work
Hertfordshire and West Essex
Who will lead?
- District / Borough Councils with Essex Public Health
- ECC Integration and Partnerships
- Hertfordshire Public Health
- Essex LEP
- Hertfordshire LEP
Timescale
Years 2 – 3 (2024/2025-2025/26)
Governance
To be confirmed
What we will do
Work in partnership with residential/care homes to enable them to become more integrated into our communities.
Area of work
Hertfordshire and West Essex
Who will lead?
- Essex County Council
- Hertfordshire County Council
Timescale
Years 3 – 4 (2025/2026-2026/27)
Governance
ICS Frailty Board
What we will do
Promote and embed Connected Lives principles in Hertfordshire and share learning with West Essex.
Area of work
Hertfordshire and West Essex
Who will lead?
HCC Adult Care Services
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
ICS Frailty Board
What we will do
Develop, publicise and share ‘simple tools’ for people who are supporting or caring for others i.e., young carers, parent/family carers and adult carers on self-care.
Area of work
Hertfordshire and West Essex
Who will lead?
- Hertfordshire County Council
- Essex County Council
- Herts and West Essex ICB
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
ICS Frailty Board
What we will do
Ensure carers are listened to and that their views/needs are incorporated into our strategies and action plans (e.g. increased availability of carer’s breaks).
Area of work
Hertfordshire and West Essex
Who will lead?
- Hertfordshire County Council
- Essex County Council
- Herts and West Essex ICB
Timescale
Years 1 – 3 (2023/2024-2025/26)
Governance
ICS Frailty Board
What we will do
Review Multi-Disciplinary Team approaches to supporting people with complex needs during discharge (approach taken during pandemic) by taking a joined up approach through auditing how things are going, share best practice and use opportunity to develop in areas not currently well covered by bringing in the VCFSE sector.
Area of work
Hertfordshire and West Essex
Who will lead?
- Hertfordshire County Council
- Essex County Council
- Herts and West Essex ICB
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
ICS Frailty Board
What we will do
Align Intermediate Care and Discharge to Assess future model, monitor success, and identify impact where there is a focus on personalisation.
Area of work
Hertfordshire and West Essex
Who will lead?
- Hertfordshire County Council
- Essex County Council
- Herts and West Essex ICB
Timescale
Years 1 – 3 (2023/2024-2025/26)
Governance
ICS Frailty Board
What we will do
Map current provision of health checks (40 – 74; learning disability (LD) and severe mental illness (SMI) across Hertfordshire and West Essex to understand how these are currently delivered across the system to ensure a focus on improving access, experience, and outcomes (reducing inequalities).
Area of work
Hertfordshire and West Essex
Who will lead?
- Hertfordshire County Council
- Essex County Council
- Herts and West Essex ICB
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
To be confirmed
What we will do
Conduct a review of health checks, where it is offered (places) and uptake.
Area of work
Hertfordshire and West Essex
Who will lead?
- Hertfordshire County Council
- Essex County Council
- Herts and West Essex ICB
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
To be confirmed
What we will do
Identify one area of focus for year one, ensuring all health checks, and people have an opportunity to have a ‘health check’ or series of, in places that suits them – e.g. one stop shop including VCFSE.
Area of work
Hertfordshire and West Essex
Who will lead?
- Hertfordshire County Council
- Essex County Council
- Herts and West Essex ICB
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
To be confirmed
What we will do
Consider joint commissioning approach where services span health/social care/public health (e.g. adult health improvement, healthy hubs) including a joint project with District Councils, VCFSE sector and active community involvement to encourage signposting to services following health checks including Learning Disability and Severe Mental illness health checks.
Area of work
Hertfordshire and West Essex
Who will lead?
- Hertfordshire Public Health
- Essex Public Health / ECC Adult Social Care
- Herts and West Essex ICB
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
To be confirmed
What we will do
Develop a system of ongoing monitoring and reporting of take up and outcomes of health checks at a local level to ensure health check offer across the system is meeting need, accessible and improving outcomes, and contributing to reducing inequalities.
Area of work
Hertfordshire and West Essex
Who will lead?
- Hertfordshire Public Health
- Essex Public Health
- Herts and West Essex ICB
Timescale
Years 1 – 3 (2023/2024-2025/26)
Governance
To be confirmed
What we will do
Learn from best practice in multi-disciplinary team approaches in West Essex through joint working and shared learning to transfer good practice into Herts.
Area of work
Hertfordshire and West Essex
Who will lead?
- HCC Adult Care Services
- ECC Adult Social Care
- Herts and West Essex ICB
- VCFSE Alliance
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
ICS Frailty Board
What we will do
Audit and map against good practice in West Essex to identify how multi-disciplinary team working can be strengthened in Herts, including bringing in the VCFSE.
Area of work
Hertfordshire and West Essex
Who will lead?
- HCC Adult Care Services
- ECC Adult Social Care
- Herts and West Essex ICB
- VCFSE Alliance
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
ICS Frailty Board
What we will do
Learn from Proactive Care work which is live in West Essex with the Integrated Neighbourhood Teams and emerging in Herts.
Area of work
Hertfordshire and West Essex
Who will lead?
- HCC Adult Care Services
- ECC Adult Social Care
- Herts and West Essex ICB
- VCFSE Alliance
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
ICS Frailty Board
What we will do
Use learning to strengthen multi-disciplinary team working in Hertfordshire.
Area of work
Hertfordshire and West Essex
Who will lead?
- HCC Adult Care Services
- ECC Adult Social Care
- Herts and West Essex ICB
- VCFSE Alliance
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
ICS Frailty Board
What we will do
Ensure multi-disciplinary linkages so that those treated at home do not become lost to view and become at risk of deconditioning.
Area of work
Hertfordshire and West Essex
Who will lead?
- HCC Adult Care Services
- ECC Adult Social Care
- Herts and West Essex ICB
- VCFSE Alliance
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
ICS Frailty Board
What we will do
Map accessibility of available information and advice offer to people, and families affected by dementia.
Area of work
Hertfordshire and West Essex
Who will lead?
- Hertfordshire County Council
- Essex County Council
- Herts and West Essex ICB
- District / Borough Councils
- VCFSE Alliance
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
Hertfordshire Dementia Steering Group and Essex Equivalent
What we will do
Work together as a system to identify all services and support available for people with dementia.
Area of work
Hertfordshire and West Essex
Who will lead?
- Hertfordshire County Council
- Essex County Council
- Herts and West Essex ICB
- District / Borough Councils
- VCFSE Alliance
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
Hertfordshire Dementia Steering Group and Essex Equivalent
What we will do
Involve residents and carers in the development of a holistic information and advice offer.
Area of work
Hertfordshire and West Essex
Who will lead?
- Hertfordshire County Council
- Essex County Council
- Herts and West Essex ICB
- District / Borough Councils
- VCFSE Alliance
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
Hertfordshire Dementia Steering Group and Essex Equivalent
What we will do
Promote information and advice offer to staff and public across the ICS and ensure this is integral to our no wrong door approach. For example, promotion of dementia cafés.
Area of work
Hertfordshire and West Essex
Who will lead?
- Hertfordshire County Council
- Essex County Council
- Herts and West Essex ICB
- District / Borough Councils
- VCFSE Alliance
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
Hertfordshire Dementia Steering Group and Essex Equivalent
What we will do
Identify and understand Mild Cognitive Impairment (MCI) and support offer in Hertfordshire.
Area of work
Hertfordshire
Who will lead?
- Hertfordshire County Council
- Herts and West Essex ICB
- VCFSE Alliance
Timescale
Years 1 (2023/2024)
Governance
ICS Frailty Board
What we will do
Once pathway identified review areas of need for those with MCI and their carers to improve area and services, with learning from West Essex.
Area of work
Hertfordshire
Who will lead?
- Hertfordshire County Council
- Herts and West Essex ICB
- VCFSE Alliance
Timescale
Years 1 (2023/2024)
Governance
ICS Frailty Board
What we will do
Review dementia training offer for health and social care workforce and address any identified gaps, using learning from West Essex.
Area of work
Hertfordshire
Who will lead?
- Hertfordshire County Council
- Herts and West Essex ICB
- VCFSE Alliance
Timescale
Years 1 – 2 (2023/2024-2024/2025)
Governance
ICS Frailty Board
What we will do
Roll out dementia training to health and care workforce in Hertfordshire, monitor take up and evaluate impact.
Area of work
Hertfordshire
Who will lead?
- HCC Integrated Commissioning Service
- Herts and West Essex ICB
- VCFSE Alliance
Timescale
Years 1 – 2 (2023/2024-2024/2025)
Governance
ICS Frailty Board
What we will do
Joint working across health and social care to develop and test/pilot assistive technology in consultation with practitioners, partners, residents and families e.g. smart sensors and a professional dashboard to collect and present data of a resident’s activity in their home to assess if this can inform more targeted care plans.
Area of work
Hertfordshire
Who will lead?
- HCC Adult Care Services
- Herts and West Essex ICB
- VCFSE Alliance
Timescale
Years 1 – 2 (2023/2024-2024/2025)
Governance
To be confirmed
What we will do
Use findings from evaluation of assistive technology pilot to inform next steps in rolling out use of assistive tech.
Area of work
Hertfordshire
Who will lead?
- HCC Adult Care Services
- Herts and West Essex ICB
- VCFSE Alliance
Timescale
Year 1 (2023/2024)
Governance
To be confirmed
What we will do
Work jointly with HWE ICB to deliver the ICS digital strategy theme on AT/prevention and living well at home.
Area of work
Hertfordshire
Who will lead?
- Herts and West Essex ICB
Timescale
Year 1 (2023/2024)
Governance
To be confirmed
What we will do
Roll out assistive technology (AT) emergency and preventative alerts in Hertfordshire, building on the pilot, and incorporating prevention of admission and community support services for responding to non-urgent AT alerts for people who require support. This aims to prevent further deterioration of an emerging health or social care issue and utilising alternative intervention to an ambulance call out.
Area of work
Hertfordshire
Who will lead?
Herts and West Essex ICB
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
To be confirmed
What we will do
Work to join up the implementation of countywide care technology service with different systems that support independence, prevention, and early intervention through:
- Building on tech enabled discharges at scale supported by a dedicated hospital post
- Explore the use of short-term assessment equipment in health pathways and how Care Technology can support virtual wards
- Add health data to strengthen the predictive analytics work to help forecast demand and target interventions
- Joint collaboration with North East Essex Care Technology Hub.
Area of work
West Essex
Who will lead?
Herts and West Essex ICB
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
To be confirmed
What we will do
Work to expand falls prevention technology in year 2 and new technology in year 3 of the Digital Tech Fund.
Area of work
West Essex
Who will lead?
Herts and West Essex ICB
Timescale
Years 2 – 3 (2024/2025-2025/26)
Governance
ICS Frailty Board
What we will do
Consider steps to integrate wider support from the community for the person and their family (a whole family support approach to end of life).
Area of work
Hertfordshire and West Essex
Who will lead?
Herts and West Essex ICB
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
ICS Frailty Board
What we will do
Increase early identification of people who are likely to be in the last 12 months of their life, so they are offered advanced care planning and personalised care and support is planned with them and their family.
Area of work
Hertfordshire and West Essex
Who will lead?
Herts and West Essex ICB
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
ICS Frailty Board
What we will do
Work to reduce the number of patients in end of life suffering crisis and requiring regular A&E attendance and in the last year of life and ensure coordinated end of life support is put in place.
Area of work
Hertfordshire and West Essex
Who will lead?
Herts and West Essex ICB
Timescale
Years 1 – 2 (2023/2024-2024/25)
Governance
ICS Frailty 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