Agenda item

Integrated Community Care Portfolio

(This report on behalf of the Lincoln Clinical Commissioning Groups updates the Committee on the implementation of the Integrated Community Care portfolio and the progress that has been made in Neighbourhood Working)


Consideration was given to a report by Sarah-Jane Mills, Chief Operating Officer, Lincolnshire West Clinical Commissioning Group, on behalf of the Lincolnshire Sustainability and Transformation Partnership in relation to the Integrated Community Care Portfolio.  It was reported that the Lincolnshire health and care community had all committed to working in partnership to realise the ambition that the default position was that care would be provided in the community unless there was a clinical need or value for money reason that care and treatment should be provided in an acute hospital setting.


The Committee was advised that neighbourhood working was the foundation for making this happen and across Lincolnshire, twelve neighbourhood areas had been identified.  In these neighbourhoods colleagues from all agencies, statutory and voluntary, would come together to support the needs of the local population.  The term neighbourhood team was used to describe how professionals worked together to support the needs of an individual.  It was a way of working that was similar to the 'team around the child' framework, not as single team rather than teams of professionals providing co-ordinated, person centred care to an adult with complex needs.


Members were provided with the opportunity to ask questions to the officers present in relation to the information contained within the report and some of the points raised during discussion included the following:

·         It was noted that 14% of the population of the Skegness area had been diagnosed with type 2 diabetes.  However, it should also be remembered that a lot of people had moved into this area after retiring.

·         Resilient communities were about building relationships within a community to support people to manage their own conditions.

·         Neighbourhood teams had consistently been one of the key developments recognised to improve integration since Lincolnshire Health and Care was initiated six years ago.

·         It was queried what feedback from GP's had been like, and members were advised that this had been very positive, and the more they engaged then the more they saw benefits in terms of serving the local population.

·         It was commented that liaison was very important, including with the third sector and smaller community groups, and it was queried how this was being addressed.  Social prescribing played an important part in the NHS Long Term Plan, particularly around identifying those smaller local groups in an area so that teams could understand the smaller but valuable things that were taking place.  It was noted that there was a lot of work taking place with staff, and if they were out in the community and noticed information about a community group they would pass on that information.

·         It was noted that 'micro-commissioning' was taking place in other rural locations so that people could make the best use of services.

·         It was noted that communication was critical.  If a health and care professional, had access to all the relevant information their decision making for a patient would be improved. 

·         It was also highlighted that councillors knew their communities well and if they became aware of any small community groups or events to pass on this information.

·         It was highlighted that work had been taking place around prevention for a long time, and it was queried how the current work was different from work which had been done before.  There was a need for caution that major problems were not being overlooked.

·         Assurances were sought that the move towards neighbourhood teams would not be a replacement for proper care provided by GP's.  Members were advised that this was not the intention, and there was a need to need create local services so that if people needed to see a GP or other health professional that they were able to quickly get an appointment.  The neighbourhood teams would not replace that, they would identify those individuals that had more complex needs and required a more personalised care plan. 

·         It was emphasised that these teams would not replace urgent health care services, but would complement those services already in existence and would help people in those situations where there was more of a social care need rather than a health need, and services would be designed around the individual rather than their disease.

·         It was noted that GP's and health professionals spent a lot of time seeing people who did not have an actual health need at that time.

·         It was commented that the north of Lincolnshire, particularly around Caistor was not served well medically, and it had been hoped that a new medical centre would be built in the next two to three years and that this would encourage more doctors to come to the area.  It was also reported that many carers in this area worked from Market Rasen, and this highlighted the difficulties that those living in the more isolated hamlets faced, as they may only have access to call connect or rely on neighbours to access services.

·         It was suggested whether services could be made better use of if they were clustered.

·         It was noted that cross boundary working was not just an issue in the north of the county.  People tended to cluster around primary care networks rather than the county or district boundaries.  Health colleagues were working with partners over the borders, and work was underway to try and resolve these complexities with CCG partners.

·         In relation to the map provided in Appendix 1 to the report, concerns were raised that there was a large disparity in the figures when looking at population numbers for each neighbourhood.  Members were advised that the Primary Care Network (PCN) would help to address some of the issues as a PCN should serve between 30,000 – 50,000 people.  For example, one network would cover Gainsborough, and in the Grantham and Stamford area there would be at least two.

·         The services provided in a particular area would be shaped and influenced by demographic need.  For example, in Skegness and Mablethorpe there was a higher need for diabetes services.  The complexity was in terms of community assets.  It was possible that there could be one area with a lot of community groups and another with very few.  There was a need to look at how these areas could work together so these assets could be built up in other areas.

·         It was queried how this would work for rural areas, as it could take between 30-45 minutes to get to the person.  It was noted that capacity and demand would be important.  From a management perspective, there was a need for a culture shift to think about the needs of an individual rather than what the organisation could do.  To work in a way that was focused around the person, and not just their medical condition.

·         Capacity would be released by managing staff more efficiently, for example, by having one person travelling to see all patients in one area rather than three travelling separately to the same area. 

·         It was noted that neighbourhood teams were made up of those people that already worked in those areas.

·         It was commented that this was a good initiative and needed to gather more momentum. 

·         Digital technology would be a big part of supporting integrated community care.

·         The work by KPMG would provide the basis for a vision where the details could be developed further.  It was the staff on the ground that understood the detail, and the critical issue was how this detail could be included in the process and understanding what it would mean for people using the service.

·         It was noted that KPMG had brought technical skills in terms of modelling and analysing data and providing that expertise that was needed.  There had been a lot of engagement with the people involved in delivering services.

·         It was commented that this had been a long time coming, but was not quite there yet.  Neighbourhood teams would not work unless there were health services there to back them up.

·         It was confirmed that there were no changes planned to the services that GP's provided, however, there may be changes to the number of outlets.




            That the comments made in relation to the Lincolnshire Sustainability and Transformation Partnership's Integrated Community Care Portfolio be noted.

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