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The Gwent health community, which consists of 11 statutory organisations, has been working together to develop a shared vision for the delivery of a comprehensive and seamless care pathway for frail people.

It is aimed at keeping individuals well and ‘happily independent’ for as long as possible. This article describes the journey taken by the community to achieve this and where we are today.

Background and Context
The Gwent healthcare community currently comprises one large acute, community and mental health NHS trust, 5 Local Health Boards (LHBs) responsible for commissioning and planning of services for their local populations, 5 local authorities (LAs) and the voluntary sector. This represents a complex environment in which to commission and manage an effective, responsive and joined up service. In January 2008, the chief executives across the Gwent Health Community, in recognition of the failings of the system and the rising costs for continuing health care, decided a radical proposal was needed to change the system. Its objectives were to provide a more timely, co-ordinated and proactive approach to preventing the onset of frailty and to provide the right level of care, while improving the “experience” for people who need assistance.

Against this local background, successive studies, most recently the Wales Audit Office work on Delayed Transfers of Care, have highlighted the need for radical change towards whole systems management within the care sector. Existing health and social care provision is under severe strain at a time when the economic climate for the private and public sector is in freefall and unlikely to improve in the short or medium term.

The Frailty Pathway was chosen for the redesign project because, as Fig.1 illustrates, it cuts across traditional boundaries between primary and secondary health care and between health and social care. The social, environmental, physical and mental health needs of frail people are so closely intertwined that it simply does not make sense to try to meet them in anything other than an integrated way. There is already a great deal of evidence to support the premise that the Gwent Frailty Programme approach is effective in maintaining independence for longer.

Fig.1 Frailty Pathway

(Adapted from the National Institute of Innovation & Improvement)

Organisation
Early discussions to determine the scope of the project and outline the model were taken forward through a range of multi-disciplinary and multi-agency workshops supported by task and finish groups. One of the key strengths of the project is that the initial strategic premise was built upon by those working directly with the client/patient group, focusing on what needed to change from their perspective in order to achieve the shared outcome that frail people would be happily independent. This meant that there had to be ownership across disciplines. The combination of expertise from those with direct experience of delivering services and strong leadership messages about a willingness and empowerment to effect radical change has proved very powerful.

One of the first pieces of work to be undertaken was a consultation exercise with potential users which worked on the premise that ‘people are the experts in their own life’. Engagement events led by the chief executive of Age Concern Gwent, asked older people in Gwent what being ‘happily independent’ meant to them.

This early work led to the creation of a vision document for the new service model, which was formally signed off by all eleven chief executives in March 2009. A Frailty Pathway Programme Board led by the chief executive for Torfaen LA was then established to formalise the ongoing work programme. Its aim is to produce a full business case to go to the Minister for Health and Social Services by October 2009.

The programme has a dedicated project manager overseeing seven working groups established for the following areas:

• Communications and stakeholder engagement
• Workforce planning
• Governance and structure
• Outcome indicators, performance and continuous improvement
• Information sharing and single point of access
• Locality planning and interfaces
• Capacity modelling and finance

Key Features of the Pathway
The model brings together a range of principles, policies and evidence which argue for the necessity of a significant shift in the way public services work with our communities for people who are frail. It is based on the definition of frailty which includes:
Dependency (chronic limitations on activities for daily living with one or more functional, cognitive or social impairments; vulnerability (‘running on empty’. An overall loss of physiological reserves and loss of functional stability); and co-morbidity (e.g. older people with chronic conditions - health and social care needs). This definition aims to provide services based on need as opposed to age. However, it excludes children under the age of 18 years.

The majority of people who meet these criteria are very old and are often admitted to hospital for non specific symptoms and diagnoses, including long term conditions, dementia, continuing health care, palliative care needs, falls and mental health.

It covers those areas where specialist and specific treatment within the acute sector is not needed or is counter-productive.

The Frailty Programme seeks to:

• build upon existing core services such as primary care, home care and district nursing
• develop additional services to ‘fill the gaps’
• work in a more co-ordinated and integrated way to ensure that frail people have a seamless experience

This is illustrated in the ‘jigsaw diagram’ in Figure 2.

Figure 3, also on the next page, shows how the pieces of the jigsaw illustrated in Figure 2 will be delivered by the operational teams, some of which will be new, but others existing already via established and core services.

All the health and social care professionals and specific care staff of a given locality, e.g. social workers, district nurses, therapy staff, clinicians, will be expected to provide for the needs of their residents in ONE approach covering the three different responses:

• Crisis
• Reablement
• Longer Term Care (including Continuing NHS Healthcare)

These are provided within a context of a range of community services that people need or choose to use to sustain their independent living. This approach will build up a local knowledge of who receives services and may need to receive them, which in turn should lead to a more pro-active approach to managing the frailty needs of a defined population. The sharing of knowledge and better coordination of care will be an important factor in building greater confidence in the ability to keep people independent and anticipate crises and/or deterioration.

Services will be available to people in their own homes, including those who live in care homes. As a consequence, reablement will become located largely within the community rather than the acute setting. This will necessarily require movement of professional staff and resources to the new service model.

An essential part of the locality approach is to integrate longer term care, including continuing health care, palliative care and aspects of chronic conditions management. This will ensure that people receive assistance sensitively and consistently even if their needs change or stabilise. It will also help to maximise economies of scale with regard to availability of resources within localities.

Key Challenges and Questions
This model requires radical change to the current ways of working. These include:

• Ability to maintain the integrity of local partnerships
• A challenging timetable for implementation
• Workforce planning and cultural shifts
• Governance issues
• Transitional funding

Ability to maintain the integrity of local partnerships
Robust partnerships are needed to achieve full integration, while maintaining the integrity of the many individual statutory and non-statutory agencies. In October 2009, as part of the reorganisation of NHS Wales, the existing LHBs and NHS Trust will be dissolved, to be replaced by a single LHB with responsibility for the planning and delivery of all health services within the Gwent catchment area. This presents a number of risks.

Firstly, the incoming board may have different priorities and so fail to provide the leadership and high level support currently enjoyed by the programme. To mitigate this, the Programme Chair has raised the profile of the enterprise by showcasing the pathway work at meetings with the Minister for Health and Social Services and senior officials. She has also secured early meetings with the Chair and Chief Executive of the new organisation and formalised support from other partner organisations. Even so, the transition process for the reorganisation is likely to have some degree of negative impact in terms of slowing down the already ambitious timetable for implementation.

A challenging timetable for implementation
The programme aims to produce a full business case for the new service model by October 2009 and begin implementation in the first locality by the end of March 2010, with full implementation across the remaining 4 localities envisaged by end of March 2011.

Workforce planning and cultural shifts
In the meantime, there are significant workforce planning challenges to overcome. These include changing ways of working and the mindset of health and social care professionals, as well as public and patient expectations. It may be difficult to recruit sufficient numbers of workers to allow the system to provide the level of expansion and re-balancing needed. GPs need to have confidence in the robustness of the community infrastructure or else they will not refer patients.

The programme is responding to these risks through the creation of a work stream to look at workforce planning and organisational development requirements.

Governance issues
There is also a governance work stream to develop good interface and partnership arrangements which clarify roles and responsibilities for a range of different responses and handover arrangements. A further work stream is tasked with developing information sharing protocols and a single point of access. The ability to identify and measure success is being developed by another work stream which is building on the work of the user group and developing a performance management system that uses outcome indicators instead of measuring outputs. This is an innovative approach being closely monitored by Wales Audit Office as a potential model for other services.

Cutting across all these strands, the Gwent Health Community has recently created a multi-disciplinary Clinical Champions Team, which includes:

· 7 GPs
· 1 practice manager
· 3 community nurses
· 2 therapists
· 1 community pharmacist

The role of the Clinical Champions team is to collectively facilitate clinical modernisation using a collaborative multi-professional approach. Part of their remit therefore, is to support the development of the Frailty pathway and engage GPs and other primary and community care staff with its implementation. This is a major innovation which is expected to make a significant contribution to effective integration and partnership working.

Transitional funding
Finally, and predictably, there are risks around the availability of transitional funding to pump prime the development and support implementation. In Wales, monies for Continuing Healthcare have been reserved by Welsh Assembly Government, to support radically new ways of managing and preventing the need for long term health care. The Frailty Programme has already been successful in releasing some of this funding in support of the pathway, because of its potential to fulfil this aim through its focus on maintaining independence and supporting people closer to home. The purpose of the full business case is to determine the future capacity and demand for the new service model, identify the potential for resource shifts within the existing pool of health and social care and secure further resources from the CHC reserve.

Conclusion
In conclusion, the Frailty Programme in Gwent represents a radical approach to service redesign based around the holistic needs of frail individuals to stay ‘happily independent’ for as long as possible. There are significant challenges to be overcome, but the community has made good progress on developing this Gwent wide service model to date. The programme benefits from excellent leadership and very strong and visible support from the executive teams of all 11 partner organisations, senior clinicians and voluntary sector partners and this has had a significant effect in terms of creating a “can do” attitude with project participants and front line staff.

Angela Fry
Project Director – Community Based Services
Lynda Chandle
Project Manager – Gwent Frailty Project
Pradeep Khanna
Consultant Physician and Chief of Staff for Community Services
Moyna Wilkinson
Corporate Director Social and Housing Services, Monmouthshire County Council

BGS Newsletter, July 2009
Issue 22 ISSN 1748-6343 22