Let’s start with what Living Well is not. It is not a project, it is not owned by the NHS and is not a one-size-fits-all solution. By virtue of what it is not as much as what it is, successful integration is more likely. Living Well is an approach to helping people who are at a crisis point in their lives, to re-engage with their communities. At its core is the ‘guided conversation’ between equals – a voluntary sector worker trained in motivational interviewing talking to someone who has become highly dependent on formal care, often socially isolated, about their hopes and ambitions. This is the foundation for a tailored package of support delivered by integrated care team.
We have learned that what matters to people who are in crisis – bearing in mind that our cohort is comprised of people who have at least 2 long term conditions and are regularly in and out of hospital – is rarely connected to their health. Whether it’s helping to rearrange a kitchen, making a rag rug or taking a ride in a vintage plane, the key is finding the spark that will motivate the person to re-engage. Health and wellbeing improvements happen almost as a side-affect. Providing a health response, or even an integrated health and social care response, is therefore unlikely to make a long term impact on that person’s situation.
Our ambition towards integration is much bigger – we are aiming to bridge the gap between the person, the statutory services around them and the largely untapped resource offered by their community. Integration to us means a co-ordinated health, social care and voluntary sector team with strong links to local ‘community makers’. It means the practitioners within that team are used to working together, taking responsibility for inefficient practice and designing simple solutions. It means that local people are involved and engaged in developing the vision for their own communities.
The Living Well approach is working: a matched cohort analysis has demonstrated that emergency department attendances have reduced by nearly a third, emergency hospital admissions have reduced by 37.4 per cent and there is a net saving of £1,500 per person per year across the whole system.
These are the key ingredients for integration that we have learned over the last five years of developing the Living Well approach:
- Local governance – local management Boards with members drawn from a wide range of interest groups and include health, social care, voluntary sector, police, housing and elected members from the Council steer the development of Living Well in each locality, chaired by a GP champion.
- Strong clinical leadership – primary care and particularly GPs are well placed to lead Living Well, being the first port of call for a person approaching crisis. Our GP champions are also mandated GPs with a clinical commissioning role within the Clinical Commissioning Group.
- Senior executive sign up – all health and social care providers as well as the broader Public Sector Group and the Health and Wellbeing Board have signed up to the aims and principles of Living Well, i.e. to improve health and wellbeing; improve the experience of care; and to reduce the cost of care.
- Knowledge exchange – Living Well has grown from pilot sites that are able to test and learn quickly, sharing what’s working and adapting what’s not. The Knowledge Bucket is our toolkit for working in this new way – as well as our resource for people and practitioner who want to share their stories.
- Measure what matters – often people’s ability to work effectively together and to do what’s best for the person at the centre is inhibited by reporting requirements. We have developed our Outcomes Framework with all our partners and adhere to the Living Well Triple Aims, which seek to demonstrate an impact across all three components of personal wellbeing, people’s experience of care and the system.
- Practitioner design and multi-disciplinary team working – this is the core of the locality based integrated care teams, which have been developed ground-up over a number of months and even years, with facilitation from the Living Well team. Our way of working is to bring together people working across a broad range of disciplines and sectors in a specific location, to reflect on practice and behaviour with a view to working better together. In one area this has resulted in a mental health nurse freeing up more than a day a week by agreeing a simplified referral process.
Integration has become a buzz word but for us the concept is simple: it starts with a conversation – know the names of the people you work with and for, and keep the person in the centre of it all.