Agenda item

The Chair welcomed those present to the meeting.  Mr Gary Collier, the Council’s Health and Social Care Integration Manager, advised that this was the Committee’s second session in relation to its review of Adult Social Care early intervention and prevention.  Witnesses had been invited to talk to the Members about neighbourhood working and preventative services such as reablement and the bridging care service. 

Mr Edmund Jahn, Chief Executive Officer at Hillingdon GP Confederation, advised that the Confederation was a Community Interest Company that had been made up of all of the GP practices in Hillingdon to provide them with support and help them to work in partnership with organisations such as the Council.  Mr Jahn was the Senior Responsible Officer for the development of neighbourhoods in Hillingdon for the healthcare sector, so GPs had been taking the lead in this area. 

Neighbourhood working could be described as “a collaborative approach where local communities and statutory services work together to improve the health and wellbeing of their population”.  However, because partners tended to work in silos within organisational boundaries, neighbourhood working aimed to break down those barriers in the interest of wrapping care services around individuals and communities.  Mr Jahn noted that it was often easier to work in silos but that working within a matrix provided a better experience for the service users. 

Integrated Neighbourhood Teams (INTs) were thought to be a team of teams which included nurses, GPs, mental health practitioners, therapists, social care workers, health visitors, etc, that had their work organised in the neighbourhood geography.  They worked together at management levels and on a practical day to day basis around the needs of patients and residents.  Whilst accountable to their own organisation, each member of the INTs would also work into the neighbourhood leadership team. 

The INTs collectively owned a neighbourhood development plan which identified what needed to change to improve access for residents.  This way of working meant that the team would be able to recognise elements of care that were not within their professional remit and discuss these with other members of the team that were able to help.  This ‘no wrong front door’ approach would be more complex for staff but more effective and more personalised for the patients as it would avoid the ‘ping pong’ experience. 

Hillingdon had been recognised as being a well-developed Borough in comparison to the other seven boroughs in North West London (NWL) and would be classed as a Level 3 on the Integrated Care Board’s maturity index.  That said, there was still a lot to do.  Mr Jahn advised that, in order to move up from Level 3 to Level 4 on the maturity index, the management team would need to let the professionals get on with their jobs (for example, the development of a respiratory clinic had created an open environment for the teams) and look at how to make the finances work differently. 

It was recognised that getting staff to get upstream of the demand for services whilst still providing a reactive approach did produce a resource bump whilst they ran in parallel or were being duplicated in the community and acute settings.  However, it was anticipated that, in 2-3 years, the service would be able to demonstrate a cost saving. 

There were opportunities to invest in local infrastructure and create greater efficiencies through the reduction of duplication and quicker responses.  The challenges faced were largely related to organisational culture and the time that it would take to break down barriers but also in relation to shared finances (organisations had a tendency to protect what they had when finances were tight despite being able to do more when working collaboratively).

The Committee was advised that Key Performance Indicators (KPIs) were being developed by NWL to measure success in relation to issues such as obesity, vaccinations, cancer screening and Emergency Department (ED) admissions (GPs already had more than 200 KPIs, as did the hospital and community services).  The KPIs were owned by the Neighbourhood Leadership Team collectively.  It had been recognised that preventative action would be key and it was noted that criteria was being developed in Hillingdon to help create movement for some of the local priorities.

Mr Jahn noted that the same day urgent care service had impacted on the number of presentations in the Emergency Department (ED) at Hillingdon Hospital  but he would forward the actual numbers to the Democratic, Civic and Ceremonial Manager for circulation to the Committee.  Although the number of attendances had decreased significantly, the acuity of the patients and the number of admissions had not gone down. 

Hillingdon partners had been working on the neighbourhood concept since 2017, but this work was now accelerating.  The Care Connection Teams had GPs, social prescribers, community matrons, etc and there were around 4,400 patients at any one time that made up around 50% of all non elective admissions.  It was anticipated that this work would reduce hospital admissions by around 41%. 

Work had been organised geographically with integrated paediatric clinics bringing together paediatric consultants with GPs in neighbourhood settings and one quarter of clinics being delivered in the community, providing opportunities to upskill local nurses and GPs.  These clinics had been running for about seven years and were now the highest performing service with the lowest waiting list in London.  The Care Home Service was being delivered collaboratively by primary care with community matrons and the Same Day Urgent Care Service established in 2023 was now running at three Neighbourhood Hubs.

Mr Jahn advised that adult social care and public health had been well embedded into neighbourhood leadership and neighbourhood decision-making in Hillingdon.  Public health, in particular, had been instrumental in defining the priority needs of Hillingdon’s neighbourhoods.  Although the Council and adult social care were not yet thought to be truly integrated within the INTs, this was a journey.  Leadership teams and plans had been well integrated but more still needed to be done as, of the 140 services that were commissioned, 10 services were thought to be fully integrated.  These could therefore be used as a template for transforming the other services.

Members were advised that the emphasis in the areas that INTs wanted to develop would depend on the population in that area.  For example, residents in the south of the Borough tended to be younger than those in the north of the Borough and had a higher prevalence of mental health issues in younger people and diabetes.  In the north of the Borough there were higher numbers of patients with hypertension, dementia and frailty / falls.  The population profiles would be different depending on the local population. 

Mr Gee Bafhtiar, Chief Executive Officer at Comfort Care Services, advised that the Government, through the NHS 10 Year Plan, aimed to reduce the pressure on the system, prevent inappropriate referrals and delayed transfers of care, and maximise integrated community-based care and independence.  Each area delivered services in different ways that were responsive to local needs: bridging care, reablement care and step-down beds.

It was noted that the intermediate care pathway was not always linear and that step down care had been developed to help with reinstating independence.  If it was agreed by adult social care that an individual would be able to go back into the community, action was taken to help them transition back to their own home or to interim care. 

Bridging care provided the opportunity to stabilise a patient before their transition back home.  It offered personalised support and would generally be in place for 1-5 days. 

Reablement care went beyond stabilising an individual, focusing on enabling patients, and lasted for up to six weeks.  About 20% of referrals into reablement care came from the community and might result in a variety of outcomes including patients going home with no further need of support or being admitted to a nursing home, etc.  It was noted that referrals were made to the reablement service as a preventative measure and reduced the number of ED presentations.  Mr Collier advised that there had been a 60% increase in the number of referrals from the community to the reablement service in the last year. 

Whilst partnership working was key, it was recognised that this was easier to say than it was to deliver.  As such, there might be a need to suboptimise to gain improvements.  There would be a need for senior managers to take ownership because coming together would make stakeholder engagement easier.  The end-to-end process needed to be mapped and clear accountabilities established.  Mr Bafhtiar advised that, as individuals tended to use Comfort Care’s services for a maximum of six weeks, bottlenecks needed to be identified and resolved as quickly as possible.  The organisation monitored a number of KPIs and was held to account by Mr Collier for achieving these. 

There had been a number of key success factors in the delivery of services which included senior management ownership and the ambition and willingness to change.  Value based recruitment had been responsive to the fluctuations in demand and extensive training had meant that staff were able to help residents to help themselves.  Mr Bafhtiar advised that the turnover of Comfort Care Services staff was not high but that staff leaving did have an impact on the knowledge base available.  As such, it was important to upskill new staff as quickly as possible. 

It was projected that there would be 1,738 bridging care service users during 2024/25 with 24% having no further needs, 53% needing reablement, 8% requiring long term care and 10% needing hospital readmission.  The average stay would be 6.4 days.  With regard to reablement, it was projected that there would be 1,192 service users in 2024/25.  87% of these individuals would have had their aims achieved within an average stay of 28 days (against the maximum of 42 days).  The Hillingdon intermediate care system would achieve this through effective partnerships, a robust working model and recent pathway enhancements.  The Hillingdon Adult Social Care Outcomes Framework of short term measures had improved from 80% in 2022/23 to 89.1% in 2023/24 (compared to 79.4% nationally and 77.6% in London). 

Mr Bafhtiar advised that there were challenges which included the ability to meet fluctuating demand, recruiting skilled professionals, the increasing complexity of service user needs and reducing the average length of stay (which would be done through expediting the transition to long term provision).  Opportunities included: leveraging integrated digital systems to improve transparency, forecasting demand and collaboration; using AI-powered health and environment monitoring to personalise care and reduce hospital readmissions; and tighter integration and partnership working with community resources. 

With regard to the use of AI, Mr Bafhtiar advised that sensors and devices such as smart watches could be used to monitor.  This use of technology would also enable the forecasting of needs and expected recovery based on patterns of data which would mean that health professionals were able to intervene at the earliest opportunity. 

Mr Collier advised that the tech-enabled care offer provided an opportunity for INT colleagues to prevent the escalation of need – this would be discussed in more detail at the meeting on 19 June 2025.  Mr Bafhtiar noted that partners were making the investment to deliver these improvements but that care needed to be taken with regard to data sharing.  Consideration was being given to the development of a framework. 

The approach being taken by the INTs was likened to the Buurtzorg Model which was a nurse led model of holistic homecare that supported independent living in a community setting.  Mr Jahn noted that a neighbourhood should be small enough that relationships could be developed across the boundaries and should empower people from multiple organisations to make decisions about the way forward. 

Members queried whether Comfort Care Services was able to identify improvements between themselves, adult social care and health partners and whether the commissioning arrangements allowed them to innovate.  Mr Bafhtiar advised that the system was not configured to working in partnership so action was being taken to address this.  He noted that it was easier to make immediate decisions when the services were collocated and that sometimes work was undertaken together and forgiveness sought afterwards.  Management supported staff to get on with the job and provided them with supervision. 

There was an expectation that Comfort Care Services would innovate as part of its contract.  Mr Collier noted that the organisation had been good at innovating and that the Council needed to not be too prescriptive and allow them to identify solutions to problems that arose.  Ms Jan Major, the Council’s Assistant Director Direct Care & Business Delivery, advised that partnership working required an open conversation and the Council would only get involved if issues could not be resolved.  The authority had a flexible relationship with Comfort Care Services, which was one of the Council’s key providers. 

Concern was expressed that there would be a limit on what Comfort Care Services could deliver when the population was increasing and the budget was being squeezed.  Mr Bafhtiar advised that this did provide a challenge but there were still opportunities to squeeze more out of the system.  He understood that the Council needed to receive value for money and noted that they had not yet reached capacity. 

It was noted that, once the recommendations for the review had been drafted, they would be shared with those present for comment.

RESOLVED:  That:

1.    Mr Jahn forward information on the impact of the same day urgent care service on the number of presentations in ED to the Democratic, Civic and Ceremonial Manager for circulation to the Committee;

2.    the recommendations for the review be shared with those present for comment; and

3.    the discussion be noted.