Caring Together in Eastern Cheshire

The aim of Caring Together is to deliver a new system of health and social care across Eastern Cheshire that joins-up local care for all our wellbeing.  It’s about the providers of care working with the people who receive care, their support networks, family, friends and carers.

This is your Caring Together Engagement HQ - a place where you can find information, view our latest updates, share your experiences, tell us your views and get involved.

For more information on how to join the conversation, and why, read the campaign leaflet.

The aim of Caring Together....Read more

The aim of Caring Together is to deliver a new system of health and social care across Eastern Cheshire that joins-up local care for all our wellbeing.  It’s about the providers of care working with the people who receive care, their support networks, family, friends and carers.

This is your Caring Together Engagement HQ - a place where you can find information, view our latest updates, share your experiences, tell us your views and get involved.

For more information on how to join the conversation, and why, read the campaign leaflet.

The aim of Caring Together is to deliver a new system of health and social care across Eastern Cheshire that joins-up local care for all our wellbeing.  It’s about the providers of care working with the people who receive care, their support networks, family, friends and carers.

This is your Caring Together Engagement HQ - a place where you can find information, view our latest updates, share your experiences, tell us your views and get involved.

The Caring Together programme is being led by NHS Eastern Cheshire Clinical Commissioning Group in partnership with Cheshire East Council, and supported by East Cheshire NHS Trust, Cheshire & Wirral Partnership NHS Foundation Trust and the 23 GP Practices across Eastern Cheshire.

The focus is on:

  • finding out what works and what doesn’t for all involved
  • sharing experiences, knowledge and information
  • improving communication between everyone
  • finding out what is stopping care being integrated and working around it
  • taking out duplication and confusion
  • giving people the help they need so they can take charge of their care.

To contact us please:

  • Call - 01625 242 511 
  • Email - join@caringtogether.info
  • Freepost to - FREEPOST: RTGC-EBAX-HHZH, NHS Eastern Cheshire CCG: CARING TOGETHER, 1st Floor, West Wing,   New Alderley Building, Victoria Rd, Macclesfield, SK10 3BL

News

  • Working Together to put patients first

    Partnerships

    Health chiefs have launched a pioneering service that helps people return home safely and happily after a spell in hospital.

    The Working Together partnership in Eastern Cheshire sees various health organisations co-operating to ensure that patients get the ongoing care they need to live independently at home following discharge.

    The scheme is managed day to day by care co-ordinators Hollie Home and Louise Rycroft who contact health partners to put in place a wide range of support which might include home visits by:

    ·  District nurses to change wound dressings

    ·  Occupational therapists to....Read more

    Health chiefs have launched a pioneering service that helps people return home safely and happily after a spell in hospital.

    The Working Together partnership in Eastern Cheshire sees various health organisations co-operating to ensure that patients get the ongoing care they need to live independently at home following discharge.

    The scheme is managed day to day by care co-ordinators Hollie Home and Louise Rycroft who contact health partners to put in place a wide range of support which might include home visits by:

    ·  District nurses to change wound dressings

    ·  Occupational therapists to install equipment such as grab rails and stair lifts

    ·  Physiotherapists to help patients walk again after surgery.

    Started in July, Working Together has already helped more than 200 patients and, although it is early days, evidence is building that the service is reducing hospital readmissions – which is good news for patients and the taxpayer alike.

    The scheme is funded by NHS Eastern Cheshire Clinical Commissioning Group(CCG) in partnership with Bollington Medical Centre; McIlvride Medical Practice and Priorsleigh Medical Centre, Poynton; and School House Surgery, Disley.

    The CCG will review the innovation after 12 months and will then look to extend it across the area’s remaining 19 GP practices if it has achieved its aims.

    Based at Priorslegh Medical Centre, Hollie and Louise receive hospital discharge notes forwarded to them by GPs from all four practices. They also have permissions to browse hospital discharge lists to make sure no patients have slipped through the net.

    They then contact the patient and their family to ensure that ongoing health needs are understood and can be met.

    Of the 300-plus patients or carers who have contacted the service so far, more than 200 have needed practical help at home as well as general advice.

    Jacki Wilkes, the CCG’s associate director of commissioning, said:

    “Working Together is a ground breaking service for 33,000 patients across four GP practices.  It provides a single point of access for patients in Bollington, Disley and Poynton who may need extra help to settle back in at home after hospital discharge.

    “As well as sourcing care, the service educates patients and their carers to give them the confidence to manage their own healthcare. I cannot think of a better example of the Caring Together ethos being applied in practice.”

    Working Together calls on the expertise of partners including Macmillan Cancer Support and district nurses, community physiotherapists and occupational therapists, care agencies, voluntary organisations and local authority social care teams.

    The following comments are typical of the overwhelmingly positive feedback from patients so far:

    “Everything has been sorted. Thank you so much for your help. What a fantastic service!”

    “This is so helpful. It will be great for me and my husband.”

    “You are a God send and I’m more than impressed with the service.”


    by CharlesMalkin 08 Dec 2014, 02:48 PM
  • Snow White's the fairest of them all

    Ambulances

    Cheshire health leaders have developed a system that is the fairest of them all when it comes to managing demand for health and social care services when winter bites.

    The Snow White urgent care dashboard was invented by NHS Eastern Cheshire CCG to provide a real-time view of the local health system and enable patients to receive excellent, timely care.

    Local GP practices were involved in its development and have sung its praises for the difference it has made.

    Information such as availability of GP appointments, available beds in hospitals and care homes, and ambulance turnaround times....Read more

    Cheshire health leaders have developed a system that is the fairest of them all when it comes to managing demand for health and social care services when winter bites.

    The Snow White urgent care dashboard was invented by NHS Eastern Cheshire CCG to provide a real-time view of the local health system and enable patients to receive excellent, timely care.

    Local GP practices were involved in its development and have sung its praises for the difference it has made.

    Information such as availability of GP appointments, available beds in hospitals and care homes, and ambulance turnaround times is fed into a special spread sheet by organisations including East Cheshire NHS Trust, Cheshire and Wirral Partnership NHS Foundation Trust, Cheshire East Council and North West Ambulance Service.

    The spread sheet even includes a daily weather forecast.

    The information enables decision makers to see at a glance which parts of the system are under pressure and which have spare capacity. Early information allows health professionals and managers to predict numbers of patients moving through the health and social care system at different times, exemplifying the joined-up approach that Caring Together is encouraging.

    Launched last winter, Snow White has been praised by NHS England. The CCG has presented the system at NHS conferences in London, Leeds and Bolton where other health organisations have expressed interest in using it.

    Named after the seven categories of information it holds, Snow White is the brainchild of Jacki Wilkes, the CCG’s associate director of commissioning.

    Former nurse Jacki said: “I wanted to have the local health system on a page, using real-time information that would enable colleagues to see which parts of the system are under pressure.

    “I asked our quality team to design a reporting system using red, amber and green traffic lights that would be easy to understand at a glance and that wouldn’t contain lots of unhelpful graphs.

    “Snow White gives us early warning of changes in demand. For example, if the weather forecast is for a big drop in temperature in five days’ time, we can ensure staffing levels are adjusted accordingly. We can also put out warning messages to our population with advice on self-care and prevention.

    “Similarly, if we’re expecting an increase in hospital admissions, we can take steps to make sure enough intermediate care beds are available in community hospitals following patient discharge. We can also gear up the integrated care teams working out of our 23 GP practices.”

    Last winter, Snow White ensured that health partners taking part in a daily conference call did not have to waste time trying to understand where the system was under strain. Instead, they were able to identify the pinch points in seconds and then spend the rest of the meeting making sensible decisions.

    Angela Wales, practice manager at Priorslegh Medical Centre, Poynton was involved in developing Snow White:

    “The urgent care dashboard is a really innovative idea enabling health organisations to have a true understanding for the first time of the winter pressures facing healthcare providers including GP practices.

    “For example, I doubt that anyone outside our practice would have known before last winter that we can take up to 500 telephone calls on a Monday between 8am and 12 noon. That sort of detailed information is vital because it allows managers to predict what will happen in the system. For example, if the GP practices are busy, we know that some patients will take themselves to A&E even if it’s not the right place for them.

    “This understanding enables the various parts of the health system to plan ahead. Equally importantly, it gives our communications teams the information to fine tune the timings of campaigns encouraging people to choose the right service, to self-medicate where appropriate and to take the steps needed to stay well during the winter.”

    The reporting system was developed by Anita Mottershead and Andy Wilson. They named the system Snow White because it held seven categories of data when first unveiled – as in the number of dwarves who looked after the famous Disney character.

    “The fact that Snow White is also a fitting name for a winter pressures system was just a happy coincidence,” confessed Anita.

    by CharlesMalkin 04 Dec 2014, 04:34 PM
  • Caring Together takes centre stage at conference

    Independence

    CCG transformation manager Bernadette Bailey flew the flag for Caring Together at a high-profile conference at Mere Golf and Spa Hotel, Knutsford last month.

    Organised by Peaks & Plains Housing Trust, the event offered lots of great examples of ways in which health and social care providers work together to help frail and vulnerable people live independently. Bernadette talked about the importance of decent housing to good health and said that Peaks & Plains and other housing providers were vital partners of Caring Together in delivering joined-up health and social care.

    Bernadette and colleagues also represented....Read more

    CCG transformation manager Bernadette Bailey flew the flag for Caring Together at a high-profile conference at Mere Golf and Spa Hotel, Knutsford last month.

    Organised by Peaks & Plains Housing Trust, the event offered lots of great examples of ways in which health and social care providers work together to help frail and vulnerable people live independently. Bernadette talked about the importance of decent housing to good health and said that Peaks & Plains and other housing providers were vital partners of Caring Together in delivering joined-up health and social care.

    Bernadette and colleagues also represented Caring Together in the health and social care market place outside the conference hall. They handed out literature, showcased the Caring Together pop-up panels and spoke to delegates about the programme.

    Keynote speaker was Falklands War hero Simon Weston OBE, who described the role played by health and social care providers in rebuilding his life after he suffered 46 per cent burns in 1982 when the Sir Galahad was destroyed at Bluff Cove.

    by CharlesMalkin 04 Dec 2014, 04:20 PM
  • Intermediate care spares pensioner hospital stay

    Working_together

    Seamless intermediate care (IC) improved the health of a frail, elderly woman and enabled her to carry on living at home.

    Mrs S was referred to IC services by her GP after a series of falls injured her left hip, causing pain when she moved. She also had dementia and was being cared for by her terminally-ill husband who had refused treatment so he could remain with his wife.

    An IC assessment at home found that she was only able to move from her seat with the aid of a carer and walking frame. As a result, she....Read more

    Seamless intermediate care (IC) improved the health of a frail, elderly woman and enabled her to carry on living at home.

    Mrs S was referred to IC services by her GP after a series of falls injured her left hip, causing pain when she moved. She also had dementia and was being cared for by her terminally-ill husband who had refused treatment so he could remain with his wife.

    An IC assessment at home found that she was only able to move from her seat with the aid of a carer and walking frame. As a result, she was sleeping in her riser/recliner chair.

    IC arranged for her to be visited twice daily by a support worker to help with personal care, dressing, pressure relief and nutrition. Equipment was put in place to aid mobility and her family was asked to help remove obstacles around the living space.

    Following an assessment by an IC physiotherapist, a daily exercise programme was started to improve mobility and reduce the risk of falls. The GP prescribed treatment for Mrs S’s low mood and sleep apnoea, and she was referred to the continence service. Cheshire Fire and Rescue Service carried out a fire risk assessment and Age UK was asked to broker a long-term care package. Mr S was referred to Macmillan Cancer Support while he and his daughter were offered a carers’ assessment.

    Thanks to IC services, Mrs S’s mobility improved and she was able to return to sleeping in her bed which, in turn, enabled her husband to rest. Her general health also improved, supporting Caring Together’s conviction that joined-up local care is good news for wellbeing.

    by CharlesMalkin 04 Dec 2014, 04:07 PM
  • There's no time like the present, says former RAF pilot

    Speed

    Caring Together’s vision of integrated care in Eastern Cheshire can’t come soon enough for 91-year-old Macclesfield man Jack Spencer.

    Not only is the former RAF pilot concerned that he won’t live long enough to see the new care model implemented. As a pastoral leader for the town’s United Reformed Church, he has witnessed first-hand the pressing need for joined-up care that enables people to live independently at home – where they want to be. He said that he knew of at least five parishioners from his pastoral group who had not benefited from much-needed home visits following hospital discharge.

    ....Read more

    Caring Together’s vision of integrated care in Eastern Cheshire can’t come soon enough for 91-year-old Macclesfield man Jack Spencer.

    Not only is the former RAF pilot concerned that he won’t live long enough to see the new care model implemented. As a pastoral leader for the town’s United Reformed Church, he has witnessed first-hand the pressing need for joined-up care that enables people to live independently at home – where they want to be. He said that he knew of at least five parishioners from his pastoral group who had not benefited from much-needed home visits following hospital discharge.

    Therefore, Jack welcomed the impending publication of the public documents spelling out how Caring Together would develop over the next few years. He was also pleased by this month’s launch of the STAIRRS service (Short-Term Assessment, Integrated Response and Recovery Service) which will see a wide range of health and social care professionals working together to make sure patients get the care and support they need as they return home.

    While Jack said he supported the Caring Together approach, he also stressed the need for health and social care decision makers to keep their eye on the ball and ensure the existing system was fit for purpose while the changes were being made.

    Jack said: “Health and social care are hugely expensive and I’m sure will always be so. But I’m convinced it would be more cost effective if it were truly joined up, allowing people to live at home and reducing hospital admissions. That’s why I think Caring Together is taking the right approach.”

    Jack was introduced to Caring Together by his GP at Cumberland House Surgery following a serious hernia operation last year which would have benefited from six weeks of post-operative intermediate care. However, he was not granted the care because he did not meet the conditions. He felt aggrieved by this because he was 90 years old at the time and was living alone, having lost his wife and both daughters in 2009.

    Jack enjoyed a successful career in telephone engineering, logistics, sales and youth training after leaving the RAF. He has lived in Macclesfield for 52 years.

    by CharlesMalkin 04 Dec 2014, 03:55 PM
  • NHS England backs self-care approach

    Healthy_living

    Healthcare professionals in Eastern Cheshire are to be trained to help people with long-term conditions look after themselves better.

    NHS Eastern Cheshire CCG is one of only three CCGs in the north of England to have been chosen by the NHS-based Year of Care Partnership for dedicated training of health workers supporting people with conditions including COPD, diabetes and heart failure. The award will pay for one and a half days’ training for four clinicians from each of five pilot GP practices from across the area.

    The training will take place before next April, leading to the development....Read more

    Healthcare professionals in Eastern Cheshire are to be trained to help people with long-term conditions look after themselves better.

    NHS Eastern Cheshire CCG is one of only three CCGs in the north of England to have been chosen by the NHS-based Year of Care Partnership for dedicated training of health workers supporting people with conditions including COPD, diabetes and heart failure. The award will pay for one and a half days’ training for four clinicians from each of five pilot GP practices from across the area.

    The training will take place before next April, leading to the development of a care plan for every patient with a long-term condition. Healthcare professionals including GPs, practice nurses and community matrons will work together with patients on the plans, putting an end to unnecessary and disjointed reviews – and enabling people to take more responsibility for their health.

    CCG transformation manager Bernadette Bailey explained: “This is a model for delivering personalised care that will give people the knowledge, skills and confidence to manage their condition in the context of their everyday life.”

    The approach exemplifies the Caring Together vision of “joining up local care for all our wellbeing” because it will support people to live well and stay well by accessing joined-up care when they need it.

    Trainees from the pilot practices will be responsible for working with colleagues and patients to improve self-care and then to share their new approaches with the area’s other 18 practices. The CCG will pay to backfill the posts of practice employees undertaking the training so that normal services are not disrupted.

    The writing of the CCG’s bid to the Year of Care Partnership was led by Dr Mike Clark, GP at High Street Surgery, Macclesfield; and Karen Burton, CCG clinical project manager.

    by CharlesMalkin 04 Dec 2014, 03:46 PM
  • Landmark publications to roll off presses

    Consulting

    Early 2015 will see the publication of two important documents explaining how Caring Together will develop over the next few years.

    One will be for employees of health and social care organisations, and will explain how they will need to work together as partners to build an integrated system that meets the needs of the 204,000 people of Eastern Cheshire. Sessions will be lined up to brief staff on the contents. The other document, probably a leaflet, will explain how service providers will achieve their shared vision of “joining up local care for all our wellbeing.” Both publications will....Read more

    Early 2015 will see the publication of two important documents explaining how Caring Together will develop over the next few years.

    One will be for employees of health and social care organisations, and will explain how they will need to work together as partners to build an integrated system that meets the needs of the 204,000 people of Eastern Cheshire. Sessions will be lined up to brief staff on the contents. The other document, probably a leaflet, will explain how service providers will achieve their shared vision of “joining up local care for all our wellbeing.” Both publications will describe how Eastern Cheshire intends meeting the challenge in the NHS’ Five Year Forward View to break down barriers between organisations and give patients greater control of their care. The documents mark the climax to months of hard work for Cheshire East Council, NHS Eastern Cheshire Clinical Commissioning Group and NHS England.

    The vision for joined-up care in the 21st Century reflects the views of the many organisations and members of the public who have attended Caring Together’s meetings and events or had their say online.

    Programme leaders will hold a series of engagement activities and events in the first few months of the year to find out what the public and service providers think of the proposed way forward. Feedback will be taken fully into account during the development of detailed proposals for changing health and social care services.

    Once consultation findings have been considered, further changes may be needed to enable the Caring Together care model to be phased in from 2016/17.

    Our newsletter will be taking a close look at the public documents once they’ve been published. Meanwhile, the latest edition shares examples of the many great ways in which health and social care are already working as one and which Caring Together seeks to replicate and enshrine.

    by CharlesMalkin 04 Dec 2014, 03:31 PM
  • Putting Caring Together into Practice

    Practice manager, Joanne Morton, believes in the Caring Together vision for health and social care – indeed she wears the CT pin badge in her lapel at work – but she is also a realist and accepts that it is a journey that needs to be taken in short steps.

    ‘We are already seeing changes with general practice building closer relationships with other professions, but it will be a change in thinking rather than just in working practice that will improve services for patients,’ she says.

    Joanne has worked in general practice for ten years, having ....Read more

    Practice manager, Joanne Morton, believes in the Caring Together vision for health and social care – indeed she wears the CT pin badge in her lapel at work – but she is also a realist and accepts that it is a journey that needs to be taken in short steps.

    ‘We are already seeing changes with general practice building closer relationships with other professions, but it will be a change in thinking rather than just in working practice that will improve services for patients,’ she says.

    Joanne has worked in general practice for ten years, having given up her job at management consultants, Coopers & Lybrand because she wanted to escape the travelling it involved after the birth of her daughter.

    ‘My first job in practice management was at St Johns Medical Centre in Altrincham and if I’m honest, I didn’t really know what it might entail,’ she says. ‘But it came at a time when practices began to be rewarded on the basis of the quality of care delivered to patients through the Quality and Outcomes Framework.

    ‘That meant that practices needed to introduce a host of management systems – things that I was very familiar with. And GP surgeries have been at the sharp end of change ever since.’

    Five years later, Joanne moved to the Handforth Medical Centre, a practice that has five GP partners, three salaried GPs and three trainees covering a 10,000 population that represent the contrasts of Eastern Cheshire with half their patients from the deprived Colshaw Farm area and the other half from the relative affluence of Wilmslow.

    Risk stratification is central to the Caring Together programme, a system used to identify those likely to use services the most so that their care and support can be coordinated through primary, community and social care acting as one.

    ‘Proactively targeting those most at risk of becoming ill is already having a positive impact,’ Joanne explains. ‘Getting the right people in the same room to coordinate their efforts is improving the outcomes for patients.’

    By ‘right people’, Joanne means the multi-disciplinary team made up of GPs, community matrons, social services, community nurses and staff from the Cheshire Wirral Partnership NHS Trust.

    ‘We call it risk stratification which sounds cold and calculating on the face of it, but the reality is that we can focus our attention on the 200 or so people who most need our help to stay healthy and keep their independence,’ she says.

    The key to success will be the investment to support the Caring Together model, in making professional support available locally and in the infrastructure to improve coordination between the different care agencies, particularly the shared care record system.

    Equally important, but less tangible, is the change in behaviours needed to make Caring Together work.

    ‘Primary care is at a crossroads,’ says Joanne. ‘We provide a wider range of services than we did even just a few years ago and that trend is likely to continue as we saw in NHS England’s Five Year Forward View.

    ‘The ideal of a truly integrated system of primary, community, hospital and social care requires a fundamental change in culture – in changing the way we are used to working to one that could be very different to how it is now.

    ‘And for our patients, it will mean taking responsibility for their own health and wellbeing with help and support coordinated by their family doctor as part of a wider health and social care team.

    by Ian Rhodes 29 Oct 2014, 03:10 PM
  • Caring Together at John Hopkins

    There was international interest in the Caring Together programme at a symposium on case-mix organised by John Hopkins University this month.

    Bernadette Bailey from the Caring Together team was one of the speakers at the event, sharing her experience of using the Adjusted Clinical Groups System in assessing the risk of illness in Eastern Cheshire and targeting care and support to those most at risk.

    The keynote speaker was Prof Chris Ham from the King’s Fund who used the Sam’s Story video to illustrate why we need to integrate health and social care. In particular, he....Read more

    There was international interest in the Caring Together programme at a symposium on case-mix organised by John Hopkins University this month.

    Bernadette Bailey from the Caring Together team was one of the speakers at the event, sharing her experience of using the Adjusted Clinical Groups System in assessing the risk of illness in Eastern Cheshire and targeting care and support to those most at risk.

    The keynote speaker was Prof Chris Ham from the King’s Fund who used the Sam’s Story video to illustrate why we need to integrate health and social care. In particular, he referred to the King’s Fund report – Making our health and care systems fit for an ageing population.

    Bernadette spoke in detail about the work that Caring Together has been doing and the lessons learned so far in Eastern Cheshire.

    ‘It was clear that the issues we face here are very similar to those in other areas of the country,’ she said. ‘In many ways Caring Together is ahead of the game and that we are on the right track.’

    by Ian Rhodes 29 Oct 2014, 02:30 PM
  • A day in the life of a stakeholder event

    A short video of our third stakeholder event has been posted on the website giving a taster of how patients and the public have been involved in developing the Caring Together model.

    The event was different in that it featured the fictional Cranford family played by actors to illustrate how services respond now and how that could change in the future.

    As Marylyn Kerby of Peaks and Plains Housing Trust said ‘The use of actors and common scenarios was inspirational and I can honestly say that I can’t remember another workshop that was so enjoyable and....Read more

    A short video of our third stakeholder event has been posted on the website giving a taster of how patients and the public have been involved in developing the Caring Together model.

    The event was different in that it featured the fictional Cranford family played by actors to illustrate how services respond now and how that could change in the future.

    As Marylyn Kerby of Peaks and Plains Housing Trust said ‘The use of actors and common scenarios was inspirational and I can honestly say that I can’t remember another workshop that was so enjoyable and thought provoking.’

    A longer version of the video featuring the various scenarios will be available at future meetings and events.

    A report on the event can be found here.


    by Ian Rhodes 29 Oct 2014, 02:27 PM