An update on progress made in Oxfordshire since a local system review of health and social care was carried out in November 2017. The original review looked specifically at how older people move through the health and social care system, with a focus on how hospitals, community health services, GP practices, care homes and homecare agencies work together. This report identifies progress against Oxfordshire’s action plan, grouped into the following themes: strategic approach to meeting the needs of older people; culture and collaboration; winter planning; market shaping; workforce; review of pathways, points of access and services; housing– equipment and adaptations; carers; and people who fund their own care. It found that, since the initial review: system leaders had made progress to reset the culture of their organisations and develop relationships; there were examples cross-system relationships had improved outcomes for people, for example in reduction in the numbers of people who remained in hospital unnecessarily; and evidence of improved winter planning. The progress report also identifies areas requiring continued improvement, which include greater involvement of the voluntary sector, development of advice and brokerage services for self-funders, and development of the ‘discharge to assess model’.
(Edited publisher abstract)
An update on progress made in Oxfordshire since a local system review of health and social care was carried out in November 2017. The original review looked specifically at how older people move through the health and social care system, with a focus on how hospitals, community health services, GP practices, care homes and homecare agencies work together. This report identifies progress against Oxfordshire’s action plan, grouped into the following themes: strategic approach to meeting the needs of older people; culture and collaboration; winter planning; market shaping; workforce; review of pathways, points of access and services; housing– equipment and adaptations; carers; and people who fund their own care. It found that, since the initial review: system leaders had made progress to reset the culture of their organisations and develop relationships; there were examples cross-system relationships had improved outcomes for people, for example in reduction in the numbers of people who remained in hospital unnecessarily; and evidence of improved winter planning. The progress report also identifies areas requiring continued improvement, which include greater involvement of the voluntary sector, development of advice and brokerage services for self-funders, and development of the ‘discharge to assess model’.
(Edited publisher abstract)
Subject terms:
older people, integrated care, interagency cooperation, hospital discharge, leadership, planning;
This report is one of 20 targeted reviews of local authority areas looking at how people move through the health and social care system, with a focus on how services work together. The reviews look at how hospitals, community health services, GP practices, care homes and homecare agencies work together to provide seamless care for older people living in a local area. The review found that there was a clear strategic direction for health and social care in Liverpool which was focused on the needs of people living in the city and described in the strategy ‘One Liverpool’. However, the review found the experiences of people using health and social care services varied. People were not always seen in the right place, at the right time by the right person; there were inconsistencies in commissioning and provision of services. Other findings were that local people were not actively enabled to participate in service planning and delivery and that people using services and their carers were not always supported to take control in making decisions about their care. Although a neighbourhood model had been developed to bring together primary, community, mental health and social care services, the model was not being implemented with a consistent approach, with GPs not always participating in multidisciplinary meetings. The report makes suggestions of areas for the local system to focus on to secure improvement including: organisational development work to strengthen relationships, improve communication and ensure there is a shared understanding among staff; improve information flows between services, including independent care providers, to facilitate safe and timely discharges from acute hospitals; and develop the personalisation agenda with more people supported to access personal budgets and direct payments.
(Edited publisher abstract)
This report is one of 20 targeted reviews of local authority areas looking at how people move through the health and social care system, with a focus on how services work together. The reviews look at how hospitals, community health services, GP practices, care homes and homecare agencies work together to provide seamless care for older people living in a local area. The review found that there was a clear strategic direction for health and social care in Liverpool which was focused on the needs of people living in the city and described in the strategy ‘One Liverpool’. However, the review found the experiences of people using health and social care services varied. People were not always seen in the right place, at the right time by the right person; there were inconsistencies in commissioning and provision of services. Other findings were that local people were not actively enabled to participate in service planning and delivery and that people using services and their carers were not always supported to take control in making decisions about their care. Although a neighbourhood model had been developed to bring together primary, community, mental health and social care services, the model was not being implemented with a consistent approach, with GPs not always participating in multidisciplinary meetings. The report makes suggestions of areas for the local system to focus on to secure improvement including: organisational development work to strengthen relationships, improve communication and ensure there is a shared understanding among staff; improve information flows between services, including independent care providers, to facilitate safe and timely discharges from acute hospitals; and develop the personalisation agenda with more people supported to access personal budgets and direct payments.
(Edited publisher abstract)
Subject terms:
older people, information sharing, integrated care, interagency cooperation, local authorities, performance evaluation, hospital discharge;
This report is one of 20 targeted local reviews looking at how people move through the health and social care system, with a focus on how services work together for older people. Specifically, it looks at how the local system is functioning within and across three key areas: maintaining the wellbeing of a person in usual place of residence; crisis management; and step down, return to usual place of residence and/ or admission to a new place of residence. The review found there was a system-wide commitment to serving the people of Sheffield, but that system partners had not always worked effectively together. It found that although there had been improvements in information sharing and joint working, social care providers felt they were not meaningfully involved in market shaping or service development. It also found admission avoidance services were under developed and that there was a lack of integration of health and social care. Other findings included that people at risk of deterioration reported not being listened to and experiencing a crisis before they received the support they needed; and that people did not always experience safe discharges to their usual place of residence because of a lack of communication and coordination, adequate assessment and provision of services. The report suggests a number of areas for improvement. These include the need for system leaders to continue to engage with people who use services, families and carers and undertake a review of people’s experiences to target improvements; an evaluation of health and social care professionals’ skills in communication and interaction with people to establish where improvements are needed; and for health and social care to be equal partners in the system transformation programme.
(Edited publisher abstract)
This report is one of 20 targeted local reviews looking at how people move through the health and social care system, with a focus on how services work together for older people. Specifically, it looks at how the local system is functioning within and across three key areas: maintaining the wellbeing of a person in usual place of residence; crisis management; and step down, return to usual place of residence and/ or admission to a new place of residence. The review found there was a system-wide commitment to serving the people of Sheffield, but that system partners had not always worked effectively together. It found that although there had been improvements in information sharing and joint working, social care providers felt they were not meaningfully involved in market shaping or service development. It also found admission avoidance services were under developed and that there was a lack of integration of health and social care. Other findings included that people at risk of deterioration reported not being listened to and experiencing a crisis before they received the support they needed; and that people did not always experience safe discharges to their usual place of residence because of a lack of communication and coordination, adequate assessment and provision of services. The report suggests a number of areas for improvement. These include the need for system leaders to continue to engage with people who use services, families and carers and undertake a review of people’s experiences to target improvements; an evaluation of health and social care professionals’ skills in communication and interaction with people to establish where improvements are needed; and for health and social care to be equal partners in the system transformation programme.
(Edited publisher abstract)
Subject terms:
integrated care, older people, local authorities, interagency cooperation, hospital discharge, information sharing, performance evaluation;
This report is one of 20 targeted local system reviews looking specifically at how people move through the health and social care system, with a focus on how services work together. The review found that there had previously been a lack of trust among the system leaders – including the City of York Council and the Vale of York Clinical Commissioning Group - that had held back the closer integration of services. In the past 12 months, this had improved. Although there was now willingness for further collaboration at a high level, frontline health and social care services were still working in isolation from each other. Different organisations provided similar services, causing confusion for staff and the public. Some of CQC’s other findings included: people using services were not always receiving the care they needed in the right place - there were delays for people waiting to be discharged from hospital, often due to a lack of seven day services in the local area; care homes were reluctant to accept people who needed to be discharged at the weekend because of past incidents where people had been discharged with no medication or discharge summaries; older people’s transfer home or to a new place of residence was often delayed due to a lack of adult social care provision, care packages and patient choice; reablement services were not always effective – a high proportion of people who received a reablement package still required long term support or further reablement; there was no single shared case record within the City of York system – there was a poor history of sharing data and business intelligence across organisations in the system which meant that people often had to repeat their story as they moved between services.
(Edited publisher abstract)
This report is one of 20 targeted local system reviews looking specifically at how people move through the health and social care system, with a focus on how services work together. The review found that there had previously been a lack of trust among the system leaders – including the City of York Council and the Vale of York Clinical Commissioning Group - that had held back the closer integration of services. In the past 12 months, this had improved. Although there was now willingness for further collaboration at a high level, frontline health and social care services were still working in isolation from each other. Different organisations provided similar services, causing confusion for staff and the public. Some of CQC’s other findings included: people using services were not always receiving the care they needed in the right place - there were delays for people waiting to be discharged from hospital, often due to a lack of seven day services in the local area; care homes were reluctant to accept people who needed to be discharged at the weekend because of past incidents where people had been discharged with no medication or discharge summaries; older people’s transfer home or to a new place of residence was often delayed due to a lack of adult social care provision, care packages and patient choice; reablement services were not always effective – a high proportion of people who received a reablement package still required long term support or further reablement; there was no single shared case record within the City of York system – there was a poor history of sharing data and business intelligence across organisations in the system which meant that people often had to repeat their story as they moved between services.
(Edited publisher abstract)
Subject terms:
older people, reablement, integrated care, interagency cooperation, performance evaluation, delayed discharge, information sharing;
One of 20 targeted local system reviews looking specifically at how older people move through the health and social care system, with a focus on how services work together. The review looks at how hospitals, community health services, GP practices, care homes and homecare agencies work together and whether services are safe, effective, caring, responsive and well led. The review found that older people living in Stoke-on-Trent sometimes have poor experiences of care and do not always have access to the right care, in the right place at the right time because the health and social care system, led by Stoke-on-Trent City Council and Stoke-on-Trent Clinical Commissioning Group, is not working in a joined up way that is meeting their needs. The reviewers found that organisations and individuals designing and delivering services in Stoke-on-Trent were not working to an agreed, shared vision and that there was a lack of whole system strategic planning and commissioning with little collaboration. This resulted in people finding it difficult to access GP appointments, older people being delayed in hospital, and needs and care packages in the community not being reviewed as regularly as they should be. The review also identifies areas for improvement.
(Edited publisher abstract)
One of 20 targeted local system reviews looking specifically at how older people move through the health and social care system, with a focus on how services work together. The review looks at how hospitals, community health services, GP practices, care homes and homecare agencies work together and whether services are safe, effective, caring, responsive and well led. The review found that older people living in Stoke-on-Trent sometimes have poor experiences of care and do not always have access to the right care, in the right place at the right time because the health and social care system, led by Stoke-on-Trent City Council and Stoke-on-Trent Clinical Commissioning Group, is not working in a joined up way that is meeting their needs. The reviewers found that organisations and individuals designing and delivering services in Stoke-on-Trent were not working to an agreed, shared vision and that there was a lack of whole system strategic planning and commissioning with little collaboration. This resulted in people finding it difficult to access GP appointments, older people being delayed in hospital, and needs and care packages in the community not being reviewed as regularly as they should be. The review also identifies areas for improvement.
(Edited publisher abstract)
Subject terms:
older people, integrated care, health care, social care provision, local authorities, interagency cooperation, leadership;
One of 20 targeted reviews of local authority areas looking specifically at how older people move through the health and social care system, with a focus on how services work together. The review looks at how hospitals, community health services, GP practices, care homes and homecare agencies work together and whether services are safe, effective, caring, responsive and well led. The review found that there was a strong commitment and a shared vision across the local authority and the clinical commissioning group (CCG) to serve the people of Halton well. There was a positive approach in Halton to maintain people’s health and wellbeing in their own homes, with services designed for older people to keep them socially included, active and able to manage their long term conditions. There was good support for carers including those supporting people living with dementia. Halton had also recently introduced new services introduced to avoid hospital admissions, including a rapid seven-day re-ablement service and a rapid clinical assessment team. Transformation projects for care homes and domiciliary care were underway so that people’s individual needs could be met in a timely way. This had led to a reduction in the numbers of delayed transfers of care and improvements in performance. The review also identifies areas for improvement
(Edited publisher abstract)
One of 20 targeted reviews of local authority areas looking specifically at how older people move through the health and social care system, with a focus on how services work together. The review looks at how hospitals, community health services, GP practices, care homes and homecare agencies work together and whether services are safe, effective, caring, responsive and well led. The review found that there was a strong commitment and a shared vision across the local authority and the clinical commissioning group (CCG) to serve the people of Halton well. There was a positive approach in Halton to maintain people’s health and wellbeing in their own homes, with services designed for older people to keep them socially included, active and able to manage their long term conditions. There was good support for carers including those supporting people living with dementia. Halton had also recently introduced new services introduced to avoid hospital admissions, including a rapid seven-day re-ablement service and a rapid clinical assessment team. Transformation projects for care homes and domiciliary care were underway so that people’s individual needs could be met in a timely way. This had led to a reduction in the numbers of delayed transfers of care and improvements in performance. The review also identifies areas for improvement
(Edited publisher abstract)
Subject terms:
integrated care, interagency cooperation, older people, health care, social care provision, local authorities;
One of 20 targeted local system reviews looking at how older people move through the health and social care system, with a focus on how services work together. The review consideres how hospitals, community health services, GP practices, care homes and homecare agencies work together and whether services are safe, effective, caring, responsive and well led. The review found that the health and social care system in Bracknell Forest was working effectively and using an integrated approach that was having positive outcomes for older people. Most older people were receiving good quality health and social care services in a timely way. Reviewers found evidence of strong strategic leadership between Bracknell Forest Council, Bracknell and Ascot Clinical Commissioning Group and providers, with a well-established, collaborative approach to designing and delivering services. Bracknell Forest service priorities included helping older people avoid unnecessary admissions to hospital, offering older people support to stay well, and improving the capacity of homecare agencies and care homes to manage the recruitment challenges. As a result, there had been reductions the numbers of people remaining in hospital while they waited for their ongoing care to be arranged. Performance had improved and was better than comparator and national averages. The review also identifies areas for improvement.
(Edited publisher abstract)
One of 20 targeted local system reviews looking at how older people move through the health and social care system, with a focus on how services work together. The review consideres how hospitals, community health services, GP practices, care homes and homecare agencies work together and whether services are safe, effective, caring, responsive and well led. The review found that the health and social care system in Bracknell Forest was working effectively and using an integrated approach that was having positive outcomes for older people. Most older people were receiving good quality health and social care services in a timely way. Reviewers found evidence of strong strategic leadership between Bracknell Forest Council, Bracknell and Ascot Clinical Commissioning Group and providers, with a well-established, collaborative approach to designing and delivering services. Bracknell Forest service priorities included helping older people avoid unnecessary admissions to hospital, offering older people support to stay well, and improving the capacity of homecare agencies and care homes to manage the recruitment challenges. As a result, there had been reductions the numbers of people remaining in hospital while they waited for their ongoing care to be arranged. Performance had improved and was better than comparator and national averages. The review also identifies areas for improvement.
(Edited publisher abstract)
Subject terms:
integrated care, older people, health care, social care provision, interagency cooperation, leadership, local authorities;
This report is one of 20 targeted reviews of local authority areas looking specifically at how older people move through the health and social care system, with a focus on how services work together. It reviews how the system functions within and across three key areas: maintaining the wellbeing of a person in their usual place of residence, crisis management and step down, return to usual place of residence and/or admission to a new place of residence. The review found Stockport had a well-defined strategic vision for health and social care, with the five main health and social care organisations in Stockport working in partnership through the ‘Stockport Together programme’. It found examples of good initiatives to meet people’s needs and prevent admission to hospital, such as the Neighbourhood Care Model, a multi-disciplinary approach to case management incorporating GP support. It also found a commitment from all levels of staff to provide person-centred care, reduce isolation and to empower people to make decisions about their care and support needs. However, older people requiring emergency hospital admission could experience waits in A&E and were more likely to remain in hospital longer than required, often due to a shortage of homecare packages or the availability of residential care. There were also significant pressures in recruiting and retaining a sufficient workforce. Recommendations include: that care home and home care providers are better involved in the planning of hospital discharges; that the system should embed the High Impact Change model to reduce the need for people to remain in hospital longer than necessary; and for independent adult social care providers to be included in the development of the workforce strategy, to improve recruitment and retention.
(Edited publisher abstract)
This report is one of 20 targeted reviews of local authority areas looking specifically at how older people move through the health and social care system, with a focus on how services work together. It reviews how the system functions within and across three key areas: maintaining the wellbeing of a person in their usual place of residence, crisis management and step down, return to usual place of residence and/or admission to a new place of residence. The review found Stockport had a well-defined strategic vision for health and social care, with the five main health and social care organisations in Stockport working in partnership through the ‘Stockport Together programme’. It found examples of good initiatives to meet people’s needs and prevent admission to hospital, such as the Neighbourhood Care Model, a multi-disciplinary approach to case management incorporating GP support. It also found a commitment from all levels of staff to provide person-centred care, reduce isolation and to empower people to make decisions about their care and support needs. However, older people requiring emergency hospital admission could experience waits in A&E and were more likely to remain in hospital longer than required, often due to a shortage of homecare packages or the availability of residential care. There were also significant pressures in recruiting and retaining a sufficient workforce. Recommendations include: that care home and home care providers are better involved in the planning of hospital discharges; that the system should embed the High Impact Change model to reduce the need for people to remain in hospital longer than necessary; and for independent adult social care providers to be included in the development of the workforce strategy, to improve recruitment and retention.
(Edited publisher abstract)
One of 20 targeted local system reviews looking specifically at how older people move through the health and social care system, with a focus on how services work together. The review found there was a system-wide commitment to serving the people of Birmingham, but that services had not always worked effectively together. It highlighted a number of areas where improvements are needed to ensure those responsible for providing health and social care services work better together. Overall, the review found that peoples’ experience of health and social care was variable and access and availability of services was inconsistent across the city. Fewer people had the chance to exercise choice and control over their care and support - some were offered care placements in parts of the city that were not accessible to their families; some were admitted to hospital with social care needs that could have been managed more effectively and safely at home; and some people stayed in hospital for longer than they needed to. The review also found that more could be done to engage diverse communities in the planning and delivery of services to ensure that services met the specific cultural and health needs of local populations. In addition, there was not a systematic and joined up approach across the city to using feedback from people, their families and carers, about services being provided. Suggested areas for improvement include: for the system’s leadership to build on recent improvements in relationships and organisational structures by strengthening relationships, improving communication and ensuring there is a shared understanding among staff of their role in achieving the strategic vision at an operational level; and improving information sharing across health and social care, as this has proved a barrier to integrated working.
(Edited publisher abstract)
One of 20 targeted local system reviews looking specifically at how older people move through the health and social care system, with a focus on how services work together. The review found there was a system-wide commitment to serving the people of Birmingham, but that services had not always worked effectively together. It highlighted a number of areas where improvements are needed to ensure those responsible for providing health and social care services work better together. Overall, the review found that peoples’ experience of health and social care was variable and access and availability of services was inconsistent across the city. Fewer people had the chance to exercise choice and control over their care and support - some were offered care placements in parts of the city that were not accessible to their families; some were admitted to hospital with social care needs that could have been managed more effectively and safely at home; and some people stayed in hospital for longer than they needed to. The review also found that more could be done to engage diverse communities in the planning and delivery of services to ensure that services met the specific cultural and health needs of local populations. In addition, there was not a systematic and joined up approach across the city to using feedback from people, their families and carers, about services being provided. Suggested areas for improvement include: for the system’s leadership to build on recent improvements in relationships and organisational structures by strengthening relationships, improving communication and ensuring there is a shared understanding among staff of their role in achieving the strategic vision at an operational level; and improving information sharing across health and social care, as this has proved a barrier to integrated working.
(Edited publisher abstract)
Subject terms:
integrated care, older people, interagency cooperation, prevention, hospital admission, hospital discharge, access to services, joint working, commissioning, co-production;
One of 20 targeted reviews of local authority areas looking at how older people move through the health and social care system, with a focus on how services work together. Specifically, it reviews how the local system is functioning within and across three areas: maintaining the wellbeing of a person in their usual place of residence, crisis management, and step down, return to usual place of residence and/ or admission to a new place of residence. The review found there was a clear shared and agreed purpose, vision and strategy described in the Happy, Healthy at Home plan, which was articulated throughout all levels of the system. Most staff were committed to the vision and agencies were also working together to keep older people safe at home rather than hospital. Reviewers also identified examples of some good joined up interagency processes, particularly the Bradford Enablement Support Team (BEST) for reablement, the MAIDT (multi-agency integrated discharge team) and The MESH team (the medicines service at home). Overall, people who lived in Bradford were supported to live in their own homes and their communities for as long as possible and received holistic assessments that took into account all of their social and health needs based around their strengths. Suggested areas for improvement include: for system leaders need to address issues around quality in the independent social care market with a more proactive approach to contract management and oversight; clearer signposting systems to help people find the support they need, particularly for people who funded their own care; and less reliance on paper based systems when people are discharged from hospital.
(Edited publisher abstract)
One of 20 targeted reviews of local authority areas looking at how older people move through the health and social care system, with a focus on how services work together. Specifically, it reviews how the local system is functioning within and across three areas: maintaining the wellbeing of a person in their usual place of residence, crisis management, and step down, return to usual place of residence and/ or admission to a new place of residence. The review found there was a clear shared and agreed purpose, vision and strategy described in the Happy, Healthy at Home plan, which was articulated throughout all levels of the system. Most staff were committed to the vision and agencies were also working together to keep older people safe at home rather than hospital. Reviewers also identified examples of some good joined up interagency processes, particularly the Bradford Enablement Support Team (BEST) for reablement, the MAIDT (multi-agency integrated discharge team) and The MESH team (the medicines service at home). Overall, people who lived in Bradford were supported to live in their own homes and their communities for as long as possible and received holistic assessments that took into account all of their social and health needs based around their strengths. Suggested areas for improvement include: for system leaders need to address issues around quality in the independent social care market with a more proactive approach to contract management and oversight; clearer signposting systems to help people find the support they need, particularly for people who funded their own care; and less reliance on paper based systems when people are discharged from hospital.
(Edited publisher abstract)
Subject terms:
hospital discharge, older people, integrated care, information sharing, hospital admission, prevention, emergency health services, interagency cooperation, access to services, leadership;