Case study: Mid-Nottinghamshire Better Together

The Mid-Nottinghamshire integrated primary and acute care system (PACS) vanguard – Better Together – is a programme created to develop a joined-up way of working for health and social care across the districts of Mansfield, Ashfield and Newark and Sherwood. This area of Nottinghamshire, north of Nottingham city, has a population of approximately 347,000. The deprivation indices for Mid-Nottinghamshire vary considerably, with particular levels of deprivation in Mansfield and Ashfield. The demand for health and social care is increasing; there is a growing number of patients who need more complex care and the costs are rising. It is estimated that this could lead to a funding gap of £140 million in this area of Nottinghamshire alone in 10 years’ time

The wicked issue with Mid-Nottinghamshire Better Together

Reducing the length of stays in hospital, supporting effective reablement and enabling people to stay independent at home: these are all key priorities for Better Together. Staff and managers from different organisations across Mid-Nottinghamshire are already involved in working groups and discussions about how to support people with complex needs to get back – and stay safely at – home, after hospital care. However, achieving better outcomes in this area involves changing hearts and minds as well as organisational practices and processes and Mid- Nottinghamshire is still facing challenges around achieving more integrated transfers of care.

These include:

• A number of cultural barriers and frustrations between the different partners involved – there is a view held by some that the medical model dominates rather than a model that reflects both health and social care and that is person-centred.
• Pressure (and targets) to achieve quick discharge from hospital resulting in insufficient discharge planning which can sometimes lead to key issues for people not being addressed.
• Negotiations at the system level have not translated into changes at an operational level, even after a significant amount of time has been spent by leaders on this issue.

Many of the issues identified above, point to the need for greater collaboration and consensus between professionals. This is particularly true of frontline professionals who are at the forefront of trying to deliver both new models of care and also constructive conversations with people who use services and their families.

Brokering constructive conversations

The Better Together programme has undertaken an extensive programme of engagement with a wide range of stakeholders, including partner organisations, the voluntary sector, staff, patients and the public. The engagement programme heard from a wide cross-section of the public and patient community and took place via several routes and approaches. The Programme Board also established a Citizens Board, made up of eight lay members. Its function is to enable active consultation of citizens and patients before, during and after the reforms to deliver the new model of care.

As part of our action research with the site, health and care leaders expressed a desire for an independently-facilitated constructive conversation between staff and managers from across the local health economy, alongside local people from the Citizens Board, to discuss ways to improve how people are helped back home safely after hospital care.

A commitment to find solutions was evident, and the opportunity to take time out to have an open and honest conversations about the issue was appreciated, by those who attended. The event helped to identify a number of challenges that needed to be addressed collectively, including lack of communication, accountability and risk-taking, discharge planning delays, lack of capacity in parts of the system, and a lack of health and social care integration. Once these issues were identified, the event also enabled groups of staff to work together to develop possible solutions to overcome these barriers.

The learning

The Better Together health and social care partners have recently signed up to a set of principles and behaviours which they hope will help them to work together more effectively and help with addressing some of the cultural challenges and professional barriers around discharge arrangements. The principles and behaviours focus on the need for greater collaboration and consensus and include, for example:

• Encouraging cooperative behaviour between partners and engendering a noblame culture
• Learning, developing and seeking to achieve full potential by sharing appropriate information, experience and knowledge, to learn from each other and to develop effective working practices
• Working collaboratively to identify solutions, eliminate duplication of effort, mitigate risk and reduce cost.

The Better Together health and social care partners have agreed to undertake an integrated review of discharge arrangements. As a starting point, they will use the findings of this constructive conversation between staff and managers from across the local health economy and local people from the Citizens Board. A steering group of senior managers has been convened to drive the review forward. Encouragingly, this most recent event was also attended by a wider group of stakeholders from the voluntary and community sector who had a really positive impact on the conversation.