What are we trying to achieve?

To progress two of the Fuller recommendations:

• Provide more proactive and personalised care and support to people through a multi-disciplinary team approach.
• Help people to stay well for longer as part of a stronger focus on prevention of ill health.

What is Fuller?

The ‘Fuller stock take report, Next Steps for Integrating Primary Care’ is a national piece of work undertaken by Professor Clare Fuller and commissioned by the NHS which outlined a new vision for primary care that reorientates the health and care system to a local population health approach through building neighborhood teams, streamlining access and helping people to stay healthy.

What have we done so far?

22 February 2023

Health and Care Partnership

• Considered the Fuller report.
• Agreed a pilot neighbourhood working in one or two areas of Milton Keynes
• Asked the Joint Leadership Team to develop a more detailed proposal for the pilot.

The Joint Leadership Team:

• Carried out initial research on the level of need and reached a view that Bletchley would be suitable as the pilot area.
• Developed a better picture of how other areas are approaching the Fuller report and the recommendations.

13 June 2023

Health and Care Partnership

• Agreed to select Bletchley as the area to pilot neighbourhood working.
• Asked the Joint Leadership Team to prepare for a potential start of the Bletchley Pathfinder in September 2023

The Joint Leadership Team:

• Undertook initial engagement work, meeting Primary Care Network leads and sending introductory letters to Bletchley partners.
• Commissioned 13 work packages to inform the design of the Bletchley Pathfinder.

20 September 2023

Health and Care Partnership

• Approved the start of the 18-monthBletchley Pathfinder in line with the design set out in this pack.

October to December 2023 – development phase

January 2024 - Start

What informed our plans?

13 work packages informed the design, including:

• Carrying out a detailed local needs assessment.
• Gauging support from local NHS organisations.
• Talking with the local voluntary and community sector.
• Finding out the level of interest from schools.
• Looking at the role of community pharmacies.
• Getting feedback from the two town councils.
• Mapping the local public sector workforce.
• Background work on roles and ways of working.
• Asking local residents for their thoughts.

The first three projects

What we found out:

Very broad support for working more closely together from the NHS family, police, schools, the city council, town councils and the voluntary sector.

Lack of awareness of what different organisations do, how they operate and could interact better.

There are some examples of multi-agency work taking place in the neighbourhood, but they are not consistent or could be developed further.

Crime and the fear of crime a theme in resident feedback.

Local people want to see better professional co-ordination.

What we are proposing initially…

To progress the Fuller recommendations

Provide more proactive, personalised care and support to people through a multi-disciplinary team approach:

1. Create ‘Team Bletchley’
2. Develop neighbourhood ways of working.
3. Implement a neighbourhood conferencing model.

In more detail…

1. Create ‘Team Bletchley

• Focused on building relationships and trust between professionals.
• Would create multiple opportunities for engagement and dialogue.
• Some universal events, some targeted – for example older adults.
• Products like an ‘Induction to Bletchley’ could be developed.
• Inclusive - open to public and voluntary sector organisations to join.

2. Develop neighbourhood ways of working.

• All about agreeing the best ways of working together in Bletchley.
• Could resemble detailed operational procedures or something looser.
• Focus on how different sectors interact (for example schools and health).
• Will require a level of organisational sign up and commitment.
• Some form of monitoring and management probably inevitable

3. Implement a neighbourhood conferencing model.

• A way of addressing issues where multi-agency involvement is required.
• Could be family-focused or focused on a wider issue.
• Standardised, well understood model.
• Will need to be clear how it relates to other panel processes.
• Will need active management and facilitation.

The second three projects:

What we found out:

Health inequalities are worse across the board, but obesity and smoking rates stand out as much worse than elsewhere.

Too much use of emergency health care and issues without patients/planned care engagement. High number of residents have long term conditions so helping people have more control over their health and care is an important issue.

Local people liked the idea of a health coach, but also want to see more support services.

What we are proposing initially

To progress the Fuller recommendations

Provide more proactive, personalised care and support to people through a multi-disciplinary team approach:

1. Create ‘Team Bletchley’
2. Develop neighbourhood ways of working.
3. Implement a neighbourhood conferencing model.

In more detail

1. Create ‘Team Bletchley’

• Focused on building relationships and trust between professionals.
• Would create multiple opportunities for engagement and dialogue.
• Some universal events, some targeted – for example older adults.
• Products like an ‘Induction to Bletchley’ could be developed.
• Inclusive - open to public and voluntary sector organisations to join.

2. Develop neighbourhood ways of working

• All about agreeing the best ways of working together in Bletchley.
• Could resemble detailed operational procedures or something looser.
• Focus on how different sectors interact (for example schools and health).
• Will require a level of organisational sign up and commitment.
• Some form of monitoring and management probably inevitable

3. Implement a neighbourhood conferencing model

• A way of addressing issues where multi-agency involvement is required.
• Could be family-focused or focused on a wider issue.
• Standardised, well understood model.
• Will need to be clear how it relates to other panel processes.
• Will need active management and facilitation.

The second three projects:

What we found out:

Health inequalities are worse across the board, but obesity and smoking rates stand out as much worse than elsewhere.

Too much use of emergency health care and issues without patients/planned care engagement. High number of residents have long term conditions so helping people have more control over their health and care is an important issue.

Local people liked the idea of a health coach, but also want to see more support services.

What we are proposing initially…

To progress the Fuller recommendations:

• Provide more proactive, personalised care and support to people through a multi-disciplinary team approach.
• Help people to stay well for longer as part of a stronger focus on prevention of ill health.

4. Develop a Bletchley health coach model

5. Seed fund social and support clubs

6. Test programmes aimed at helping families eat well

 

In more detail…

4. Develop a Bletchley health coach model

• Based on health coaching model but with flexibility to innovate.
• Initially to be focused on smoking.
• Likely to be an ‘add-on’ to existing roles to achieve scale.
• Some existing roles may be suitable for conversion to health coach.
• Backed by training and support.

5. Seed fund social and support clubs

• Designed to fund both small social clubs and health support groups.
• Focus on lower cost clubs and groups and supporting new activities.
• Funding open to both residents and organisations.
• Simple application and reporting processes.
• Based on the successful ‘Lakes Clubs’ model.

6. Test programmes aimed at helping families eat well

• Based on a ‘test and learn’ approach, co-produced with local people.
• Targeted, focussing on families with young children.
• Emphasis on improving food skills and access to heathier food.
• Partnership approach including schools, children’s centres, primary care.
• Close working with partners such as and SOFEA and MK Food Bank.

Governance

• MK Health and Care Partnership
• Joint Leadership Team
• Agreed MK Deal Priorities

• Improving system flow - sponsors: Ian Reckless and Victoria Collins.
• Obesity – sponsors: Vicky Head and Tayo Kufej.
• Children and Young People’s Mental Health – sponsors: Jane Hannon and Mac Heath.
• People with complex health needs
• Bletchley Pathfinder Fuller – sponsors: Michael Bracey and Marimba Carr.

Responsible for:

• Creating and sustaining ‘Team Bletchley’
• Developing and agreeing neighbourhood ways of working
• Implementing a neighbourhood conferencing model

Involvement in (Public Health leading):

• Developing an integrated health coach model
• Seed fund social and support groups
• Test programmes aimed at helping families eat well

Bletchley Pathfinder Delivery Board:

Independently chaired 12 members:

• 2 Primary care
• 1 Community and mental health2 Schools
• 1 Police
• 2 City Council
• 2 Parish Council
• 2 Voluntary Sector

The £450K budget 

1. Create ‘Team Bletchley’ - £100K.
2. Develop neighbourhood ways of working. – Funding delegated to the Delivery Board
3. Implement a neighbourhood conferencing model - multi-agency training •  Practice workshops • Networking events • Communications budget • Facilitation costs.
4. Develop a Bletchley health coach model - £100K Training • Recruitment • Incentives • Supervision.
5. Seed fund social and support groups - £150K.
6. Test programmes aimed at helping families eat well - £100K.

Funding sources: £250K from the 2023 Health Inequalities ICB funding and £200K from the Public Health Grant funded Public Health Reserve.

Evaluation

1. Create ‘Team Bletchley’: Sentiment tracking amongst professionals (regular engagement).
2. Develop neighbourhood ways of working: Adherence with agreed ways of working (exception reporting).
3. Implement a neighbourhood conferencing model: Attendance and participation in neighbourhood conferencing, tracking outcomes.
4. Develop a Bletchley health coach model Record keeping by coaches demonstrating change, some record sampling.
5. Seed fund social and support groups: Numbers of groups and participants recorded. Qualitative report produced after twelve months.
6. Test programmes aimed at helping families eat well: Project level evaluation will report on impact of interventions and focus on learning.

A multi-agency initiative led by the NHS and Milton Keynes City Council