Working as One

We deliver great care every day, but we don’t always have the right resources in the right place, and we’re not as joined up as we could be. Anyone using or working in our local health and social care services will know the significant pressures staff face, especially during the ‘winter period’.

Together, we have made great strides to improve how we provide care, but in the face of unprecedented growth in levels of need, the time is right to look at how we evolve and target our efforts to meet these challenges for the people we serve. Some of the challenges we face include:

• We don’t direct people to our community services as well as we could and so our hospitals are under pressure – for example, at times an ambulance handover has taken 3 hours, and we have 70 people in the Emergency Department waiting for an acute bed
• People are staying longer in our hospitals – length of stay has risen from 6 to 9 days in the last few years
• We find it hard at times to support people’s discharge home – 1 in 4 people in our acute beds do not have a medical reason to be there
• While life expectancy continues to improve for the most affluent 10%, it has either stalled or fallen for the most deprived 10%
• Sometimes we find it hard to get the right support for people to leave hospital when they are ready- this limits the number of available beds for those who need it
• 3 in 5 people ready to be discharged from hospital do not need to be there and are awaiting onward care

The organisations responsible for health and adult social care services in Gloucestershire decided to invest in a large-scale programme aiming to improve care and services for people when they need to access care urgently. This decision was supported by Gloucestershire Integrated Care Board and NHS England, who recognise the challenges faced by our system and the financial benefits that could be delivered. We are working with a company called Newton Europe – who have experience of delivering similar transformation in other areas – who have helped us to fully understand the issues that need tackling and where the opportunities lie to make the biggest improvements to patient care, whilst delivering a financial benefit. The programme has identified opportunities to work more efficiently and in partnership leading to improved health and social care outcomes, not going to hospital when you don’t need to, reducing hospital admissions, A&E attendances and use of social care services.

In December 2022, Gloucestershire front line staff and managers, supported by Newton colleagues, came together to review over 100 patient journeys to give us a thorough understanding of the issues facing health and adult social care services , our staff and the residents that we support. Since then, staff and other stakeholders have been involved in setting up how we design what needs to be done to deliver improvements.

Our Programme vision is to deliver quality, integrated care for the people of Gloucestershire to support the best possible physical and mental health outcomes, enabling them to lead the most happy and healthy lifestyles. The programme will do this by redesigning the way care is provided in the One Gloucestershire system by all partners working together to deliver the right care, in the right place, at the right time.

The programme is structured into five workstreams:

• Prevention – To proactively support people’s independence to live and thrive in their community for as long as possible, reducing or delaying getting to the point of an urgent need.
• Community Urgent Response & Front Door – Reducing avoidable acute hospital attendances and admissions (stays) by ensuring people receive the right support, from the right service, at the right time, using alternatives to hospital where possible. When they do arrive at the hospital, improved processes will support effective treatment and links to appropriate ongoing support.
• Hospital Flow and Decision Making – Ensuring people benefit from timely referrals, tests, treatment and decision making when in hospital so their length of stay (LoS) is appropriate enabling them to be medically fit for discharge (MFD). Once MFD, patients are discharged to an appropriate setting for their needs in the minimum number of days.
• Intermediate Care/Reablement – To improve the availability, flow and outcomes of rehabilitative care in the community. To build the capacity required to allow prompt discharge from hospital (or step-up from community) into care in the most suitable location – with a Home First approach
• Access To Care Packages – To ensure availability of long-term care packages for those who require them and supporting options for family or friends providing unpaid care to the person in need. This work will look at whether improved intermediate care is a solution, or where the improvement of intermediate care is fundamentally blocked by availability.

The Working As One programme started its set-up phase in mid-2023 and has moved onto the opportunities design phase (known as “Trials”) with our clinical and operational staff in selected areas through the last few months. We will continue to learn from these trials in the early part of 2024 before scaling up and rolling-out the co-designed changes through 2024. The programme will work with our Newton colleagues for a period of 18 months, and we will need to ensure the changes are sustainable and embedded in our services, so the benefits are maintained.

As a system, we clearly understand that our Winter Assurance for 2023/24 was developed against a challenging landscape, recognising the ‘usual’ anticipated winter challenges, as well as planning for seasonal flu, ongoing impact of Covid-19 and continued industrial action and workforce challenges across Health and Social Care. Many, if not all, of the areas of focus in the Working As One Programme align with our Gloucestershire Urgent and Emergency Care (UEC) & System Flow winter plan; these include:

• Improve peoples’ experience by using a range of alternatives to A&E which means more people who need urgent (but not emergency) care will be able to be seen without going to one of the main hospitals. This will also improve the experience of people who do need emergency care in our A&E departments by reducing crowding and waiting times. Commented [B11]: Updated
• Ensure people can be discharged safely and quickly from all our health settings, working ever more closely with social care and implementing nationally recognised improvement actions.

This exciting programme started with putting into place improvements to how we work across all parts of the health and care system. That will provide a strong foundation for further transformation work in the medium and long term as we build ever-improving urgent care services for the people of Gloucestershire.

In the first instance there will be changes in areas where we undertake the trials work, but we will need to ensure that changes and benefits are scalable before we implement any changes coming out of these design groups. Embedding the new ways of working to everyone is not something that will happen overnight, but we hope to have everyone up to speed by end of 2024 and we will keep you informed along the way.

As a programme we are aware we are only one element of work among many others being undertaken in the Gloucestershire system and that there are many interconnectivities across each workstream, for example hospital flow. Many of the people in the system will work on service changes within the programme and at the same time winter plan initiatives and individual organisation transformation projects. We will need to work closely and share information and progress to ensure we are making the best use of everyone’s precious time.

The programme has dedicated governance that includes many of these people to help manage dependencies, and the programme will also regularly update both system meetings and organisation-specific meetings to help co-ordinate this.

It will depend on which area you work in and your role. The trials will test out new ways of working, this ranges from improving the processes that are currently being used, for example hospital patient Board Rounds, to work with integrated teams to help more people get the help they need to get back on track and regain independence. More broadly it may mean teaming up to share concerns, cases, information, workload, and anything else that prevents us from doing the best for the residents of Gloucestershire. This might mean doing things you’ve not done before, working with different people etc and we will share information with you when it’s available as well as providing any training you need and support along the way. For more information speak to your line manager.

Our ambition as a Programme is to

• Support working in an integrated way to provide care
• Empower staff to make decisions and provide an environment to be innovative and provide quality care
• To deliver a more connected system that helps us flex and wrap the right support around people

The central focus of the Working As One Programme is to improve internal processes across the NHS and adult social care, so professionals can make the right decisions more effectively. Any changes that patients will experience will be greater opportunities to receive the urgent care they require in the right place and at the right time. Our ambition is to ensure the residents of Gloucestershire get:

• The support to stay as healthy and independent as possible, preventing the need for care in the first place
• Are able to get the help they need in the community and at home
• Access high quality services to help you recover independence after a hospital stay – with home as the preferred route

The Programme works closely with the Gloucestershire ICB UEC Public and Communities Reference Group. The trials we undertake to test new ways of working will, of course, consider patient/resident real time feedback, to help shape the ongoing trials and ensure we are meeting the needs of those involved. We will also be working with some local people to hear lived experiences of using emergency and urgent care services and social care in Gloucestershire.

For every workstream we have set up Design Groups to set up trials and define what will be different. The Design Group will consist of a cross-section of professionals from relevant roles across the system organisations and they’ll also act as one of the liaisons between the staff and the programme for suggestions and ideas. If you want to know more contact glicb.workingasone@nhs.net

If you want to be involved in the design phase of this programme, or just want to find out more, you can contact one the Programme Leads.

Kelly Matthews Programme Director kelly.matthews1@nhs.net

Micky Griffith Programme Director micky.griffith@nhs.net