Adult Social Care & Health Alignment/Integration Programme, including voluntary sector support

Scheme

Who?

Tower Hamlets Together

Tower Hamlets Council

Tower Hamlets GP Care Group


Tower Hamlets Council for Voluntary Services

Barts Health NHS Trust

East London NHS Foundation Trust (ELFT)

Tower Hamlets Clinical Commissioning Group

What

The expansion of integrated services and the provision of a universal offer of health and social care information and advice.

This has involved aligning adult social

care systems with those of community health care to include a combined ‘front door’ and reducing duplication around rehabilitation and reablement. Voluntary sector services are part of the integrated offer.

Why?

The programme aims to improve the outcomes of individuals by enabling independent health and wellbeing. It aims to provide the following benefits:

  • support timely hospital discharge
  • reduce avoidable hospital admissions by supporting people to stay healthy and to access support earlier
  • reduce the use of GP appointments for non-medical problems.

When?

On 1 April 2017 the Tower Hamlets Together Partnership (THT) became the new provider of community health services (CHS) in the borough, enabling coordinated care to be provided outside the traditional hospital environment.


In 2018, there was alignment of adult social care services with the CHS service model.

How?

The three key work streams of the programme are as follows.

Front door/single point of access to Tower Hamlets health and social care

  • Signposting and information on available services both for residents and health care professionals
  • A seamless approach for contact by residents that helps professionals to arrange the right care for urgent and non-urgent referrals.
  • Clinical triage of patients and onward referral to appropriate services.
  • Professional support for more complex cases.

Joint intermediate care team

  • Joint health and adult social care team providing short-term rehabilitation and reablement.
  • Up to six weeks of intensive rehabilitation in the community.
  • Identifies long-term health and social care needs.

Long term care locality team model

  • Coordinated care by health and social care professionals for individuals requiring support to manage long-term conditions.
  • Co-location of multidisciplinary teams.
  • Better provision of community-based services based on locality needs and priorities.

Voluntary sector support is crucial to delivering the programme and Tower Hamlets has a Council for Voluntary Service (CVS) development programme, the objective of which is to build the capacity of the sector to respond to the changing commissioning landscape in health and social care and to become partners in the delivery of improved health and wellbeing for the residents of Tower Hamlets.

Challenges

  • The need for an increased focus on system-wide organisational, professional and cultural development to enable further progress.
  • The need for more effective communication and information-sharing between high level management and operational delivery of integrated care.
  • Differing professional cultures between health and social care professionals, for example, differing approaches to assessing risk. A need for further integration and partnership working.
  • A lack of understanding between professionals of each other’s roles, for example health professionals lack of understanding of the role of social care.
  • Differing IT systems for patient records is a barrier to sharing information, for example difficulties for social workers accessing health records.

Specific challenges for the voluntary and community sector (VCS)

  • The challenge of ensuring adequate representation of the VCS in an integrated care system due to structure and the scale of the challenge.
  • Commissioning processes and payment mechanisms can be a barrier to VCS involvement, especially for smaller organisations.
  • It can be difficult to persuade NHS and local authority staff to refer to or use a new service.

Impact

  • Tower Hamlets has seen a reduction in emergency admissions and do-not-attend rates.
  • Structural changes have enabled greater collaboration by partner organisations at the strategic level.
  • Health professionals recognise the importance of self-care and of addressing the social determinants of health.

Case study

This initiative works closely with hospitals and GPs in Tower Hamlets to engage socially isolated people, who may traditionally be reluctant to accept help and support – particularly from the statutory sector.


It signposts and refers people into support services provided by the NHS, the council and the voluntary sector. The service undertakes needs assessments in order to understand people’s requirements in their last years of life. It provides a befriending service and practical help in the home that is not covered by social services. It also provides support to carers, enabling them to have short-term ‘care-free’ time and provides holistic support (e.g. therapeutic services). It also provides preventative services to protect the health and wellbeing of both cared-for people and their carers through befriending, practical and emotional support.

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