Julie Farrow Briefing document 25 February 2016

1. Building a Health & Wellbeing Network
Context
“Cambridgeshire and Peterborough is one of 11 most financially challenged health economies in
England”. A high growth area including two new towns (estimated 15,000 homes) and predictions
of 44% increase of over 65s by 2021.
In 2013, Cambridgeshire and Peterborough CCG began the bid for the older person’s service, the
first of its kind in the country the aim of which was to shift the focus from acute to prevention.
The tender for the older persons service was predicated on a £800 million contract to provide cross
sector support to people aged 65 years and older and people with Long Term Conditions in
Cambridgeshire and Peterborough. Embedded within this contract was £1 million to third sector
organisations for current service delivery, but also an opportunity to help develop a new wellbeing
service.
In addition to this, there are a number of Health and Social Care change programmes across
Cambridgeshire and Peterborough aiming to address / improve health and well-being;
 The Public Health team across Cambridgeshire and Peterborough are running a programme
called ‘Healthy Ageing and Prevention’ on behalf of the Cambridgeshire Executive
Partnership Board. (includes third sector)
 Priority 3 for the Cambridgeshire Health and Wellbeing board is; ‘Encourage healthy
lifestyles and behaviours in all actions and activities while respecting people’s personal
choices’.
 ‘Transforming Lives’ is Cambridgeshire County Council’s in-house change programme,
looking at establishing and streamlining services access across Tiers 1, 2 and 3. People
identified as Tier 1 will need to have access to a range of health and well-being /preventative
services.
 ‘Investing in Communities’ is Peterborough City Council’s in-house change programme.
 Cambridgeshire and Peterborough CCG is one of the national Urgent and Emergency Care
Vanguards. The CCG have established a Strategic Systems Resilience Group (SSRG) that is
county wide. One of its 5 strategic aims is; ‘Promoting self-management and self-care’.
Whilst Cambridgeshire and Peterborough has a vibrant third sector it is made up of mainly small
organisations delivering in small geographical areas.
Thinking differently – drivers for change
CVS5 – the consortia of CVSs in Cambridgeshire/Peterborough worked in conjunction with
Cambridgeshire & Peterborough CCG in raising awareness within the sector of the outsourcing of the
older people’s service.
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2. During the tender period third sector organisations were targeted and courted by bidders, larger
organisations coped with the demand for meetings and information; smaller organisations struggled
to get their voice heard.
The vision - integrated health & wellbeing third sector
With this system wide focus on prevention and healthy ageing, there is a great opportunity for a
coordinated third sector to demonstrate the breadth of services it can offer and establish itself as an
innovative leader in interventions that support improvements in quality of life. As a united and
consistent collective, the development of a ‘The Health & Wellbeing Network’ providing a single
point of contact for both professionals and services users.
The aim of a more unified approach was to;
• Improve accessibility of services.
• Streamline commissioning / performance management.
• Raise the profile of voluntary organisations, encouraging them to play a wider role in
prevention and support statutory services to manage ever increasing demand.
The Health and Wellbeing Network
Developing the ‘offer’
1. Defining ‘the needs’ that ‘The Cambridgeshire and Peterborough Health and Wellbeing
Network’ may support
In order to provide a coordinated and easily accessible service whilst also demonstrating its impact
on health and well-being, ‘The Cambridgeshire and Peterborough Health and Wellbeing Network’
needed to be very clear on what interventions it will provide. The below list is based on an initial
scoping exercise completed and categorised using the Rockwood Frailty Scores / Local Authority
tiers of function.
Fit and Managing Well
(Tier 1, Rockwood 1-3)
Vulnerable
(Tier 2, Rockwood 4-6)
Frail / Significant Need
(Tier 3, Rockwood 7-9)
Nutrition / Hydration Befriending Admission Avoidance
Physical Activity Access Housing Support Carer Intervention
Social Clubs / Forums Housing Adaptations Home from Hospital
Education Opportunities Housing Access Care Package Augmentation
Volunteering Opportunities Condition Specific Groups Mental Health crisis
Access to literature and web Shopping Dementia/Delirium crisis
Support Telephone Line Transport MDT support
Signposting Bin collections End of Life
Telephone Preference Service Assistive technology
Mail Preference Service Financial well being
Advocacy
Carer Support
Mental health support
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3. Dementia / Alzheimer’s support
Pharmacy / Medication support
Pet Care
Physical and Sensory support
It is felt that Tier 1 services are those provisions that are low risk and could be provided by a variety
of local voluntary sector groups and organisations, and do not necessarily require significant
structure / governance around their reporting or activity.
2. Coordinating members service delivery
To ensure people are accessing the most appropriate intervention, from the most appropriate
service in a timely way, ‘The Cambridgeshire and Peterborough Health and Wellbeing Network’
needed to work with its member organisations to define which providers will deliver against each
need. Each member organisation should have clear parameters if they are delivering an intervention
about what information they need to share centrally with the Health and Wellbeing Network, and
adhere to time frames required for reporting.
The Health & Wellbeing Network should define what the service offering is for each Tier 2 and Tier 3
intervention, so that various organisations delivering the same service in different localities have
similar outcomes. Clarifying the service definition for each intervention will also improve
commissioners’ understanding of what the Wellbeing Service is delivering and help make the case
for on-going funding or increased funding if we want to expand services. For example, a Home from
Hospital service should have operational models that mirror each other wherever possible and the
performance data gathered for each service should be the same. For the Home from Hospital
intervention, example universal data may be; how many new patients were supported each month,
length of time each patient was supported, what specific support was delivered (i.e. shopping,
cooking, daily visit to reduce anxiety etc)
3. Single Entry Point and ‘The Cambridgeshire and Peterborough Health and Wellbeing
Negtwork’ Marketing
Navigating the Cambridgeshire and Peterborough Health and Wellbeing Network needs to be as
simple as possible for professionals and the public. A single phone number is available for enquiries
and referrals and the call centre support would then manage all onward referrals out to the most
appropriate Wellbeing Service organisations. In addition to the phone number a web site and simple
internet referral process has been developed that is based on the needs/interventions that the
services under the banner of ‘The Cambridgeshire and Peterborough Health and Wellbeing Network’
provide.
Both a phone number and website could be linked directly to 111, and to the new ‘DXS’ information
system being rolled out to GPs, contact centres at local authorities etc etc. The diagram on the
following page show the various groups / services that may refer into ‘The Cambridgeshire and
Peterborough Health and Wellbeing Service’
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4. All referrals via a call centre should be logged within a single repository IT system (see section 5
below). This would mean that a client only has to give their details once and then this information
can be shared (subject to appropriate consent) with the relevant ‘Cambridgeshire and Peterborough
Health and Wellbeing Network’ organisations providing the interventions. To manage the work load
of referrals coming into the wellbeing service, it is felt that a staggered approach to introducing a
wellbeing call centre would be ideal, with a launch specifically to GPs in the first instance and then
spreading out to other professional groups, before going wider to more public domains.
For external marketing purposes and to improve utilisation of Wellbeing Service, individual
organisation materials would need to be limited. Commitment will be required from all ‘full’
member organisations to move towards a unified marketing approach for ‘The Cambridgeshire and
Peterborough Health and Wellbeing Service’ (different membership levels are described in sections 7
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5. and 8). Individual organisational materials could be handed out when a service is directly working
with users but only once a ‘Cambridgeshire and Peterborough Health and Wellbeing Service’ referral
has been processed and an intervention put into place. An example of this may be; if a patient
requires admission avoidance support, Age UK may provide the intervention and then leave the
patient with some further information about Age UK’s other services, and other appropriate
members, e.g. Dial Peterborough, whilst the service is being delivered.
4. Capturing Activity Information – A Single Repository
If all members were to input information into a single IT system/repository, progress with
interventions could be reviewed centrally. In addition, the centralised repository system could also
allow members to report key performance / activity metrics that could be used to generate a
performance dashboard for ‘The Cambridgeshire and Peterborough Health and Wellbeing Service’ as
a single entity. This report could then be shared with the various commissioning organisations.
Performance data should be relevant to the interventions delivered and reflect the relevant
outcomes, rather than just the most easily measured.
Data from a central performance dashboard could also be used in any joint tender opportunities that
‘The Cambridgeshire and Peterborough Health and Wellbeing Service’ member organisations may
want to bid for.
5. Universal Outcome Measures
Cambridgeshire and Peterborough CCG and the Local Authorities are keen that all statutory and non-
statutory support services begin to gather universal outcome data, to measure the impact of
interventions and help define what level of support the population may need. There are two
measures that should be captured during an intervention that is delivered by any member of ‘The
Cambridgeshire and Peterborough Health and Wellbeing Service’; Frailty score and a Quality of Life
(QoL) measure.
The ‘Frailty Score’ can be obtained using the Rockwood Clinical Frailty Scale. This defines what level
of need a patient has from 1 (very fit) to 9 (less than 6 months to live). Assessing a client prior to an
intervention will allow ‘The Cambridgeshire and Peterborough Health and Wellbeing Network’ to
identify the types of clients it is supporting. Frailty scores should either be provided by a referring
professional or assessed at the first face to face contact with the organisation delivering an
intervention.
In addition, it may be that the interventions delivered by ‘Cambridgeshire and Peterborough Health
and Wellbeing Network’ organisations are not specifically implemented to improve frailty or physical
ability but they are implemented to improve quality of life. As such, a measure should be introduced
that assesses someone’s own perception of their quality of life, which should be carried out pre and
post intervention. The quality of life measure that is used needs to be defined by the commissioning
organisations.
6. Membership and Management
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6. The Cambridgeshire and Peterborough Health and Wellbeing Network membership should be an
inclusive right for all Voluntary sector organisations across Cambridgeshire and Peterborough. There
could be a distinction between ‘Full’ Members and ‘Network’ Members (please see Governance and
Reporting Structure for suggestions as to what could constitute Full vs. Network membership). The
different levels of membership may denote the type of interventions a service delivers (Tier 1, 2 or
3), what is expected in terms of reporting and what level of rigour is required over the quality /
background check / training of active volunteers.
It is proposed that the Health and Wellbeing Network would need a small operational team to
coordinate members, develop performance management processes and reports, manage marketing
and promotion, liaise with commissioning teams and programme boards around performance of its
services and help to identify additional interventions and potential funding support for new
interventions that members of the Health and Wellbeing Network may want to deliver.
For more information please contact
Julie Farrow
Chair Health & Wellbeing Network
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7. The Cambridgeshire and Peterborough Health and Wellbeing Network membership should be an
inclusive right for all Voluntary sector organisations across Cambridgeshire and Peterborough. There
could be a distinction between ‘Full’ Members and ‘Network’ Members (please see Governance and
Reporting Structure for suggestions as to what could constitute Full vs. Network membership). The
different levels of membership may denote the type of interventions a service delivers (Tier 1, 2 or
3), what is expected in terms of reporting and what level of rigour is required over the quality /
background check / training of active volunteers.
It is proposed that the Health and Wellbeing Network would need a small operational team to
coordinate members, develop performance management processes and reports, manage marketing
and promotion, liaise with commissioning teams and programme boards around performance of its
services and help to identify additional interventions and potential funding support for new
interventions that members of the Health and Wellbeing Network may want to deliver.
For more information please contact
Julie Farrow
Chair Health & Wellbeing Network
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