Joining up people, places and populations to improve local health and wellbeing and help people get the right care, faster
Over the years, a number of reforms have sought to strengthen the NHS as one of the country’s most important and beloved institutions. The dawn of Integrated Care Systems recognises it’s not just those three letters that influences the health of local communities: it’s a whole ecosystem.
Chris’s story is powerful, it helps demonstrate how individuals, community groups and local services should all be part of the same team to keep people healthy and well.
A year has gone by since Mid and South Essex Integrated Care System (ICS) was established. In this time, health and care leaders have been working together, balancing both short-term and longer-term priorities.
It is vital that local people can access the care they need now and that services remain sustainable to meet the future needs of our population.
To tackle the root causes of ill-health, we need to act differently. This report looks at progress to combine our efforts so that every pound is spent in the right way to make a difference in health and care outcomes for and with local residents.
Around 80% of health outcomes are determined by non-clinical inputs, such as education, employment, housing and the environment* solutions require actions beyond the remit of healthcare.
Working to improve outcomes in population health and healthcare
One size doesn’t always fit all. Local people with multiple conditions have told us they want services to work together to focus on their individual needs and preferences and offer better support for mental wellbeing.
Last year, John a retired driver in Benfleet, benefitted from a new joined-up approach to care. Alongside others, he had been identified as someone whose health was at risk of going downhill. A health and wellbeing coach, working as part of a GP team, helped John to identify and reach his own health and wellbeing goals.
Initial discussions around weight and exercise moved to struggles with lower back pain, low mood, tiredness and issues managing his diabetes. John’s unexpected retirement in 2020 meant he’d lost his purpose in life. He didn’t like others seeing him struggle, admitting he’d had suicidal thoughts. He spoke about financial concerns and being able to afford to take part in activities that he would enjoy, having not ventured far from his home because of his health.
The local team at the GP practice listened and worked with the gentleman and other professionals to activate a tailored health and care plan. Positive changes were immediate, with goals set to walk to the post-box with his wife without stopping and to get back into his hobby of racing pigeons. Importantly, ongoing reviews show he is feeling more positive, he’s lost some weight and is on new diabetes medication after speaking to a clinical pharmacist at his GP practice.
In the last year, more integrated neighbourhood teams have come together to deliver better co-ordinated services to local people. These teams consist of professionals from various disciplines, such as healthcare, social care and the community and voluntary sector. By working together in a ‘one workforce’ approach, teams can better understand both the specific needs of an individual and the community it supports helping develop tailored interventions to help support wellbeing.
More help in the community
Supporting, adapting and growing our workforce has been front and centre of our work in the last year.
Nearly 500 additional health and care professionals are now working in GP practices in mid and south Essex to strengthen local teams and bolster support in the community.
New social prescribers working in GP practices are helping connect people to support in their community. Initiatives like Chris’s community football team and other community groups offer non-medical support and activities to improve overall wellbeing.
Paramedics, mental health professionals, physiotherapists and pharmacists are also working as part of the GP team. The additional skillset brings more expertise into the community and help free up GPs to deliver more comprehensive care to people with more complex needs.
By offering better support for people to manage their health, GP teams can help their patients avoid stressful emergencies wherever possible.
Steve’s story explains how better access to specialist mental health support at his local GP practice meant he could access the right care faster.
Tackling inequalities in outcomes, experience, and access
We know that different groups of people have poorer health and care outcomes in mid and south Essex and health and care partners all share the same goal to change that.
In March this year we launched a new Integrated Care Strategy calling for collective action to tackle health inequalities.
Building on work during COVID-19, partners continue to join forces to reach people who wouldn’t otherwise access traditional services to keep them well.
Outreach to Gypsy, Roma, Traveller and Showman communities in Thurrock is just one example. Aside from helping to catch diseases like diabetes early and undertake important health checks, collaborative working with Thurrock Council means advice around finance, education and employment can be offered at the same time.
Working better together
Linking up data is a fundamental step in understanding which communities and groups would benefit from targeted help.
In the past year we have been working to develop a ‘single source of truth.’ By having a clearer picture we can better design services and target interventions specific to our population.
Targeted support and interventions in Southend and Thurrock is already helping to save lives and prevent more families suffering the heartache of losing a loved one through targeted lung health checks.
Dr Sophia Morris, clinical lead for inequalities has written a blog that explains how health and care partners are working in other ways to connect with our communities and find solutions to narrow the gap in health inequalities.Find out about other programmes to reduce health inequalities
Enhance productivity and value for money
This can often lead to a poor experience and duplication with people having to repeat their stories time and time again and disjointed pathways of care delaying action.
Local people deserve to experience health and care as one seamless, integrated offer of support.
Transforming care for older adults in Essex
A programme called ‘Connect’ has seen teams from across the health and care system aligned on a common goal: achieving more independent outcomes for older people.
Working together to test and iterate changes on this shared agenda has transformed care at the frontline in a way that is sustainable, measurable, and crucially, is helping us to achieve fantastic improvements to the outcomes of older people in Essex who look to us for care, while making the most of our resources across the system.
Over the last 12 months we have continued to develop a new innovative approach that places multi-professional clinical leadership at the helm, called stewardship.
Stewardship brings together people, we call stewards, from the coalface of services alongside people with lived experience related to a particular care area, i.e. cancer. They have the responsibility to re-shape how health and care services deliver value for local residents. From education, initial consultations at a GP practices, through to diagnosis, treatment and ongoing management, maximising the use of technology.
Great progress has been made by our stewards in the last year so that local people can get the right care, faster – helping to cut waiting times.
Helping to support broader social economic development
Health and care organisations are one of the biggest employers locally and play a significant role in their local community’s economic and social development. Partners from across our system have been exploring how they can make broader commitments to support local wellbeing, as an employer, procurer or advocate for carbon reduction.
The Mid and South Essex ICS Anchor programme has been working to:
- Support employment in health and social care.
- Nurture young people and families.
- Join forces with communities and partner organisations.
- Support organisations in finding opportunities to increase social value.
- Identifying ways to boost wider determinants of health.
I didn´t think I´d get my dream job. I didn´t have much confidence. I attended the Anchor Recruitment Day, feeling nervous, but everyone was so friendly and reassuring. I was offered a job as a healthcare assistant there and then! I had my first shift on 15th September and loved it.Basildon resident