1. Developing Neighbourhood Teams
Barnsley 19/20 and beyond

2. Developing neighbourhood teams
This slide pack covers:
The national plan for integrating community and primary care services.
The local plan for developing neighbourhood teams:
How neighbourhood teams can make a difference.
The scope of services involved.
The way in which the teams work together.
The timetable for developing neighbourhood teams.
Notes: Outline of the things covered in the slide pack
If you are reading this online or printing it you may find the speaker’s/reader’s notes helpful

3. What are the plans for neighbourhood teams?
NHS Long Term Plan states need for integrated working and to “finally dissolve the historic divide between primary and community health services”.
Community health services are for people with physical health conditions and are provided by nurses and allied health professionals (such as an occupational therapist for example) in people’s homes and in community clinics in the larger health care buildings.
Primary care services are all the things that your GP practice provides.
National plan in line with local discussions and developments (building on what has worked well and learning from areas like the Dearne).
This is the national context for integrated community and primary care teams. This isn’t new work for us in Barnsley as we have been developing a more aligned approach in some areas. The next steps for us will be integration of community services.
We will maintain all our community services in Barnsley. These services won’t be changing for patients in terms of the services available to them and where they are offered - it’s the way the different teams work together with each other and with primary care that will change.
However, by working in a more joined up way, we expect to see a number of improvements over time for patients as they will have more co-ordinated care and have access to some care more quickly. People who are receiving community care for the first time, or for a new condition, will continue to see a GP or nurse from their practice first. Their care will then be co-ordinated by the neighbourhood team and the GP or nurse in the practice will be working with them as one joined-up team.

4. What are the plans for neighbourhood teams?
The NHS Long Term Plan brought in Primary Care Networks in July 2019, where groups of GP practices work together to improve the health problems that are having the biggest impact on people’s lives in their area.
Barnsley Primary Care Network is now in place, underpinned by six neighbourhood networks. These form the building block to develop neighbourhood teams.
South West Yorkshire Partnership Foundation Trust (SWYPFT) and primary care teams are working with CCG and partners to develop neighbourhood teams over the coming months.
This is the national context for integrated community and primary care teams. This isn’t new work for us in Barnsley as we have been developing a more aligned approach in some areas. The next steps for us will be integration of community services.
We will maintain all our community services in Barnsley. These services won’t be changing for patients in terms of the services available to them and where they are offered - it’s the way the different teams work together with each other and with primary care that will change.
However, by working in a more joined up way, we expect to see a number of improvements over time for patients as they will have more co-ordinated care and have access to some care more quickly. People who are receiving community care for the first time, or for a new condition, will continue to see a GP or nurse from their practice first. Their care will then be co-ordinated by the neighbourhood team and the GP or nurse in the practice will be working with them as one joined-up team.

5. Local context: shared vision
Shared Barnsley model of what integrated care might look like in the future
This is the longer term vision we have in Barnsley, which includes community and primary care services and starts to describe how different teams could work together. The next slides will talk about what the actual model of neighbourhood teams will be in more detail.

6. Next steps: Making neighbourhood teams a reality
Creating community services that effectively wrap around the new primary care network (PCN) will:
Deliver the NHS Long Term Plan.
Reduce duplication to deliver better patient experience and value for money.
Help people stay well at home and out of hospital - reduce the growth we are seeing in avoidable admissions to hospital through joined up care in the community.
Support workforce transformation.
Make better use of local estates (the larger health & care buildings which house multiple GP practices, community services, pharmacies and some council services)
This slide moves us from context and vision to the detail of what neighbourhood teams will do and how they will work.
Our task now is to make neighbourhood teams a reality. We want to see more people staying well at home and not being admitted into hospital.
Neighbourhood teams can wrap around the new Barnsley primary care network and neighbourhood networks.

7. Things to consider and feedback on:
What issues do you face day to day that closer working between community and primary care could help to address?
What would give you confidence that the system is working?
What does “one team” mean to you and what would you like to see in the future?
How do you see services using technology and digital innovation to improve care for people?
How could neighbourhood teams impact on the growing number of people being admitted to hospital and what is the role of general practice and the clinical networks in helping to achieve this?
What measures would you use to know if neighbourhood teams are achieving the objectives?
We would like to hear people’s concerns and recommendations.
This slide is placed here to pause and to provide some areas to start thinking about as we move into more detail in the following slides.
At the end, we will we ask for people’s concerns and recommendations.
All questions and suggestions are welcome and some people may want to add their expertise into one or all areas – all feedback welcome.

8. Barnsley Primary Care Network & Neighbourhoods
1 x Barnsley PCN
6 x neighbourhood networks (red outline)
The Barnsley primary care network, live from July 2019, and one of the building blocks to come out of the NHS Long Term Plan published in January 2019.
Six neighbourhood networks underpin the one primary care network.
The different colours show the area council areas. Even though the areas are slightly different, it will not have an impact on what we call frontline care – health workers and social care workers and others will continue to work together to support people, irrespective of what network/neighbourhood/council area they live in.
Neighbourhood teams will work in the six neighbourhood network areas, with some specialist input working across the borough where it makes sense to.

9. What will neighbourhood teams do?
Introduce one single point of access and clinical assessment for community services.
Be everybody’s business, reducing multiple internal referrals.
Be supported by shared care records – one patient record that multiple teams can view and update.
Have a clear set of commonly agreed response times which are based on clinical need (routine, urgent, etc.)
Map to patient need – using a population health management approach to planning.
Include organisational workforce development – enhanced opportunities for staff.
Improve organisational resilience within and across teams.
Focus on patient reported outcome measures, as opposed to the ‘number of contacts’ included in current contracts.
Have a one set of key performance indicators instead of the many that exist now.
This is broad list of what neighbourhood teams will do and how they will be set up and supported.
This is where we start to see some of the things that are different to how teams are configured currently. We also see some of the things we are doing well, that we want to build on.

10. Community services in scope for neighbourhood teams
Community health services and memory assessment services for people aged 16 and over are in scope.
Mental health services are not currently in scope however there is a clear need to look at how areas will work together in the future.
There are clear interdependencies with other services run by these other organisations:
Hospitals
Council
Hospice
Voluntary Sector
Others (care homes, pharmacies, health & wellbeing services, etc.)
Neighbourhood teams focus on community services and how they work together as one, as well as how they link in with other existing health and care services.
Memory assessment services currently form part of mental health services in Barnsley and it is proposed that this service forms part of the neighbourhood teams.

11. Borough-wide services
Neighbourhood working
Core neighbourhood teams
Person at the centre
Specialist community nursing, therapy, mental health and social care services
Hospital-based services
Other primary care services, mental health, public health and prevention and social prescribing
Statutory services such as education, neighbourhood policing
Community and voluntary sector
Core nursing, therapy and care coordination through single point of access
GP and specialist input as required
All the services above designed around individual service users, families and their support networks
This diagram is designed to show that the person is at the middle of their care.
Each of the services that wrap around them are described in each section.
The diagram shows how different teams are set up. Core nursing will have nurses and therapists with a consistent set of skills and competencies to be able to treat a range of things when they see someone and they will only need to refer someone on, if they need more specialist care.

12. Single point of access: contact, triage and allocation.
One single point of access for the six neighbourhood teams
A single point of access for clinicians to refer into, or patients to contact, can be very effective in a number of ways.
At a very basic level, you have one telephone number, or online booking system where a clinician can send all the information to, which triggers the next stage of someone’s care.
There are currently a number of different points of access in Barnsley. The proposal is to bring all them together and have one, single point of access for clinicians to refer into.
Diagram taken from community services operating model guidance NHS Improvement 2019

13. Proposed phasing of community neighbourhood teams
Phase 1 (April to July 2020)
Phase 2 (by March 2021)
Neighbourhood nursing service
Memory assessment service
End of life
Speech and language therapy
Wound management and tissue viability service
Podiatry
Parkinson’s disease
Dietetics
Continence and urology
Stroke
Heart failure
Musculoskeletal (MSK)
Epilepsy liaison
Cardiac rehabilitation
Intermediate care
Pulmonary rehabilitation
Occupational therapy
Falls
Domiciliary physiotherapy
Community home loans
Equipment and adaptations
There are two proposed phases to bring the services listed into neighbourhood teams (both core and specialist).
The services listed refer to the community based aspect of any care.

14. Feedback so far
The next couple of slides show some of the questions and feedback received so far.
After these next four slides, we want to start to discuss the concerns and also recommendations you have to develop neighbourhood teams.

15. Things that have been fed back so far:
Scope:  We have received feedback about the different services included in neighbourhood teams.
We have received feedback that mental health services should also be included in the scope.
Age threshold:
We have received feedback in relation to the age threshold for people accessing the service.
Some of the current community services see people who are aged 16 and over, however, currently children’s services see people up to their 19th birthday. The NHS Long Term Plan states the need for children’s services to see people up to the age of 25.
We have received feedback that the service should see people aged 18 or over.
These things have come from colleagues working in community services and primary care, as we start to work through the detail.

16. Things that have been fed back so far:
Consistent waiting times or ‘clock speeds’: We have received feedback about ‘clock speeds’ or the time that people wait to be seen. Currently this varies depending upon which service team you are seen by and what health condition you have.
We have had feedback that all referrals should be assessed as being ‘urgent’ or ‘routine’ and be seen within according timeframes, rather than people with different health conditions being seen within a different number of days.
We have received feedback that clock speeds need to be aligned with the wider health system, such as people waiting a maximum of four hours when they attend the Accident and Emergency (A&E) department.  
These things have come from colleagues working in community services and primary care, as we start to work through the detail.

17. Things that have been fed back so far:
Single Point of Access: The Single Point of Access (SPA) will operate 24 hours a day, 365 days a year service in order to support a range of response times based on patient need.
It is expected that the core team will work:
Core 08:00–22:00 Mon – Sun
Night Service 22:00-08:00 Mon - Sun
Staffing levels and skill mix will be adjusted to reflect patient need. Therapy interventions will be routinely delivered during the day time hours (08:00-18:00) with flexibility to respond to patient need at other times.
We have received feedback about the Single Point of Access which aims to reduce multiple internal referrals.
The feedback questions whether a SPA which operates 24 hours a day, 365 days a year is necessary. A 24/7 SPA would support a key aim of the service which is that people are cared for at home, enabling them to stay well and out of hospital.
These things have come from colleagues working in community services and primary care, as we start to work through the detail.

18. Things that have been fed back so far:
These are additional areas for your consideration:
Clinical guidance (potentially out of date NICE guidance)
Governance (how governance links to PCNs)  
Information Management and technology (how the existing systems can support the new team)
Key performance indicators (benchmarking and consistency)
Mobilisation (how existing services work and how the new team will be mobilised)
Phasing (splitting service mobilisation)
Wider system interaction (how new team will slot into existing services across Barnsley).
These things have come from colleagues working in community services and primary care, as we start to work through the detail.

19. What are your concerns and recommendations?

20. Proposed next steps
We will use your feedback to review and revise the specification for neighbourhood teams.
September – begin to mobilise an agreed neighbourhood team model.
April 2020 onwards – phase 1 of neighbourhood teams begins.

21. Contact details for neighbourhood team feedback
SWYPFT: Gill Stansfield
Barnsley Healthcare Federation: James Barker
Barnsley member practices: Dr Nick Balac or directly to
Patients, carers and members of the public and anyone with an interest in developing neighbourhood teams can get involved by:
CCG
SWYPFT
Telephone the CCG on