West Yorkshire and Harrogate Health and Care Partnership Our Journey to Personalised Care
25 February 2019
Housekeeping
Agenda • Welcome & Introductions • Universal Personalised Care (UPC) • West Yorkshire and Harrogate Health and Care Partnership: purpose, vision & why we
need change? CEO Experience And Challenges Of System Working • Break & Marketplace • Workshops session • Lunch & Market Place • A Personal View • The cultures we need to support Universal Personalised Care - The stories of
Collaborative Practice. • Workshop session • Coffee Break & Market Place • Q&A Panel Session • Next Steps • Close and Networking
Hello my name is… Jo Webster, Chief Officer, Wakefield Clinical
Commissioning Group & Lead for Personalised Care
https://www.youtube.com/watch?v=Zw8A_O6R5lo
SMaSH groups in Wakefield – Self-Management and Self-Help
Hello my name is… James Sanderson, Director of Personalised Care,
NHS England &
Pritti Mehta, Head of Personalised Care, North Region, NHS England
www.england.nhs.uk
Universal Personalised Care: Implementing the Comprehensive Model
February 2019
Comprehensive Model for Personalised Care All age, whole population approach to Personalised Care
People with long term physical
and mental health conditions
30%
People with
complex needs
5%
Supporting people to stay well and building community resilience,
enabling people to make informed decisions and choices when their
health changes.
Supporting people to build knowledge, skills
and confidence and to live well with their health
conditions.
Empowering people, integrating care and reducing unplanned
service use.
Specialist Integrated Personal Commissioning, including
proactive case finding, and personalised care and support planning through multidisciplinary teams,
personal health budgets and integrated personal budgets.
Targeted Proactive case finding and personalised care and
support planning through General Practice. Support to self manage by increasing
patient activation through access to health coaching, peer support and self management education.
Universal Shared Decision Making.
Enabling choice (e.g. in maternity, elective and end of life care).
Social prescribing and link worker roles. Community-based support.
Plus Universal and Targeted interventions
Plus Universal interventions
Whole population 100%
INTERVENTIONS OUTCOMES
TARGET POPULATIONS
www.england.nhs.uk
• 86% of people said they achieved what they wanted with their PHB. 77% of people would recommend PHBs to others with similar needs.
• Independent reviews have found evidence that people’s well-being, satisfaction and experience improves through good personalised care and support planning, including for people with cancer.
• 75% of people who booked hospital outpatient appointments online felt they were able to make choices which met their needs.
• People and professionals consistently overestimate treatment benefits and underestimate harms. Shared decision making helps reduce uptake of high-risk, high-cost interventions by up to 20%.
• Local evaluations of social prescribing have reported improvements in quality of life and emotional wellbeing, as well as lower use of primary care and other NHS services. Systematic reviews have found that the quality of evidence is variable and there is a need for more evidence on the effectiveness of social prescribing.
• Personalised care and support planning has been shown to improve GP and other professionals’ job satisfaction.
• Monitoring of costs for PHB holders receiving NHS CHC home care packages found an average saving of 17%.
• An independent evaluation found that PHBs were overall cost neutral. People with a PHB had lower indirect costs through less use of secondary healthcare (average £1,320 per person per year).
• In one site, IPC was implemented at scale alongside other interventions. Following the 100-day challenge in 2017 the site saw a reduction in emergency admissions of 12%, as well as a 24% reduction in A&E attendances for the two practices which took part.
• An independent evaluation found that people who had the highest knowledge, skills and confidence had 19% fewer GP appointments and 38% fewer A&E attendances than those with the lowest levels of activation. This finding was corroborated by a Health Foundation study which tracked 9,000 people across a health and care system.
The difference personalised care makes To people’s experiences
To people’s outcomes
To the workforce experience
To the system
www.england.nhs.uk
Local examples of impact
FYLDE COAST Self-management
STOCKTON Care planning
Patient Activation Measure scores increased
by an average of 8.9% following care and support tailored to
people’s needs 24% reduction in A&E attendances in 2017 within two GP practices
12% reduction in unplanned admissions in 2017 within two GP
practices
NOTTINGHAMSHIRE Personal health budgets
£25,000 saving in transport costs for siblings with very complex health
conditions
Lease their own adapted vehicle through a personal health budget for journeys to day centre and respite,
instead of a commissioned transport package
Health improvements included average 10 point increase in EQ-
VAS scores
BRADFORD Social prescribing
74% of people increased their mental well-being after being referred to the scheme
www.england.nhs.uk
Chapter One sets out a new NHS service model for the 21st century. This will be achieved through the following five major, practical, changes over the next five years: Boost ‘out-of-hospital’ care and dissolve the divide between primary and community services 1. Redesign and reduce pressure on emergency hospital services
2. People will get more control over their own health, and more
personalised care when they need it
3. Digitally-enabled primary and outpatient care will go mainstream across the NHS.
4. Local NHS organisations will increasingly focus on population health and local partnerships with local authority-funded services, through new Integrated Care Systems (ICSs) everywhere
The NHS Long Term Plan
www.england.nhs.uk
What does this entail? • Roll out the Comprehensive Model for Personalised Care across England, reaching 2.5 million people by 2023/24 and
aiming to reach 5 million people by 2028/29 (para 1.39) • Standard models and quality indicators for each component below, ensuring quantity and quality
Component Goal by 2023/24
Shared decision making Shared decision making embedded in 30 high value clinical situations in primary care, secondary care and at the primary/secondary interface where it will have the greatest impact on experience, outcomes and cost
Personalised care and support planning
750,000 people, including people with long term conditions, people at the end of life, and pregnant women
Enabling choice, including legal rights to choice
Legal rights to choice are maintained throughout wider system transformation, with 100% of elective referrals exercising choice through the electronic Referral System and 100% of CCGs compliant with choice improvement guide
Social prescribing and community-based support 900,000 people referred to social prescribing link workers
Supported Self-Management Continue to increase the opportunities for people to benefit from supported self-management approaches
Personal health budgets and integrated personal budgets 200,000 people benefitting from PHBs or IPBs
www.england.nhs.uk
Specific Personalised Care commitments in LTP •Accelerate roll out of Personal Health Budgets… Up to 200,000 people will benefit from a PHB by 2023/24 (para 1.41)
•Over 1,000 trained social prescribing link workers by 2020/21 and 900,000 people referred to social prescribing link workers by 2023/24 (para 1.40)
•Ramp up support for people to self-manage their own health (para 1.38)
•People have choice of options for quick elective care, including choice at point of referral and proactively for people waiting for six months (para 3.109)
•Support and help train staff to have personalised care conversations (para 1.37)
•Use decision-support tools (para 3.106) and ensure the least effective interventions are not routinely performed… potentially avoiding needless harm (para 6.17viii))
30%
5%
100%
www.england.nhs.uk
Other commitments that depend on Personalised Care
• Significant commitments to support care quality and outcomes, including applying the Comprehensive Model of Personalised Care to end of life care (para 1.42), dementia (para 1.20) and cancer (para 3.64)
• Enabling more personalised care and choice and control for people with learning disabilities, autism
or both (para 3.34), children and young people (para 3.47), and people with mental health conditions (para 3.106)
• Personalised care and support planning approaches in maternity (para 3.13), CVD (para 3.70) and to
support people to manage their condition in work (appendix on health and work) • Expand supported self-management for people with long-term conditions (para 2.2), including
diabetes (paras 3.79, 5.13), respiratory disease (para 3.85) and MSK conditions (para 3.107)
• Community pharmacies will also promote and support self-management for people (para 1.10) • In addition to the above, personalised care is:
• Recognised as enabling the shift to digital and vice versa (para 5.8-5.9) • Recognised as a practical enabler of integration (para 1.58) • To be supported and enabled through the revised QOF (para 1.11)
www.england.nhs.uk
Personalised care and other programmes
Digital ⇄ Personalised Care Personalised Care and Digital complement each other in delivering modern healthcare approaches
Who: People with complex needs We will empower people, integrate care and reduce unplanned service use.
Who: People with long term physical and mental health conditions We will support people to build knowledge, skills and confidence to live well with their conditions.
Who: Whole population We will support people to stay well and enable them to make informed decisions and choices when their health changes.
• Digital health and care plans • Personal Health Budget tools to
help resource allocation, e.g. e-marketplace
• Personal Health Records to ensure better coordinated care
• Online education and treatment e.g. digital IAPT
• Digital Patient Activation Measurement
• Directory of services to support social prescribing
• Staying well, making informed choices to help the access the right care, at the right time through digital means, including the NHS website, NHS App and other health apps.
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ialis
t Ta
rget
ed
Uni
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al
Using assistive technology, Maggie can review and amend her care plan at a time and place that’s right for her; knowing that every care professional that supports her has access to it. It also means every clinician can see her care preferences.
Gary found it hard to accept that he had Type 2 diabetes. Using the patient activation measurement tool has helped him access more relevant support to build his knowledge, skills and confidence, and via the NHS Apps Library he can now use his phone to monitor his diet.
Pardeep has recently been diagnosed with a serious medical illness, which may require an operation. By accessing the NHS.uk website, he found out about the risks and benefits of the surgery, before choosing whether to proceed.
5%
30%
100%
Digital enablers This means… Personalised care enablers
Personalised care and support planning provides the standards required to support people to have access to both read and edit their Personal Health Records, which will be achieved through the NHS app
Shared decision making establishes the expectation that people are equal decision makers with clinicians, helping shape content on the NHS website
Supported self-management means increasing people's knowledge, skills and confidence (patient activation). By increasing “activation”, people can better make use of the entire suite of digital first options that Empower the Person is delivering
25 January 2019
www.england.nhs.uk
How will we deliver this? Universal Personalised Care is the delivery plan for personalised care, and sets out 21 detailed actions to achieve the systematic implementation of the Comprehensive Model for Personalised Care. These actions are summarised below
Communications, partnerships and
co-production
• Publish Comprehensive Model with standard models
• Behaviour and culture change campaign
• Support people with lived experience to be system leaders and build demand
Skills, behavior and culture change
• Training and support for clinicians and professionals
• Embed personalised care in pre- / post-education training
• Embed shared decision making into specific clinical situations
Local implementation
• Deliver Comprehensive Model in ICS, STP and PCNs
• 3 Integration accelerators
• Effective mechanisms to enable choice and control
• Implement supported self-management approaches
• PHB expansion, increasingly by default
Community-based approaches
• Social prescribing link workers in all local areas
• Explore best models for commissioning and supporting voluntary sector
Transition and infrastructure
• NHS Personalised Care
• Digital and personalised care
• Personalised Care dashboard
• Health inequalities
Levers and incentives
• Introduce new legal rights to personalised care
• Embed and use levers and incentives
• Integrate model into wider transformation and frameworks
• Include wider funding streams
Impact and outcomes
• Evidence and impact
• National Impact Statement
Hello my name is… Rob Webster, CEO for South West Yorkshire
Partnership NHS Trust & CEO Lead for WY&H HCP
Purpose, vision & why we need change?
Rob Webster
25 February 2019
#Hello my name is ……..…
Chief Executive of South
West Yorkshire Partnership NHS Foundation Trust
CEO Lead for West Yorkshire and
Harrogate Health and Care Partnership
3
West Yorkshire and Harrogate Health and Care Partnership
23
WY&H Health and Care Partnership – Our Vision
24
In 2018/19 WY&H became a Personalised Care Demonstrator Site and we have made good progress….
Social Prescribing commissioned in all
of our 6 places
Personal Health Budgets available in
all of our 6 places
Patient Activation Measures in place in
4 of our 6 places with 2 places being
mentored
Shared Decision Making trialled in 2
of our 6 places
Personalised Care & Support Planning
fully implemented in 1 of our 6 places, with a further 3
places progressing
Over 100,000 people receiving
‘personalised care’ across WY&H at
Quarter 3 2018-19
25
Where we are making a difference……
Wheelchair PHB mentor (Leeds)
The Better Living Team (Calderdale)
Motivation to Move (Calderdale)
(Leeds)
(Kirklees)
(Bradford)
26
The NHS Long Term Plan
Up to 2.5 million people will benefit from Personalised Care by 2024, giving them the same choice and control over their mental and physical health that they have come to expect in every other aspect of their life.
This includes:
• the expansion of personal health budgets with 200,000 people set to benefit from one in the next five years.
• around 750,000 people with a long term health condition will also receive a written personalised care and support plan to manage their condition.
• up to 900,000 people will benefit from social prescribing and community-based interventions by 2024.
27
What is next …… The commitments in the NHS Long Term Plan fit with our WY&H vision…“putting you at the centre of everything we do”
We will continue to apply this to all of our programmes and in everything we do
28
We are a guest in people’s lives
30
• Visit www.wyhpartnership.co.uk • Weekly blog www.wyhpartnership.co.uk/blog • ‘Our Next Steps’ www.wyhpartnership.co.uk/next-
steps • Follow: @wyhpartnership @NHS_RobW
Further information
31
Coffee break & Market place
Social prescribing workshop David Cowan
Collette Connolly Samantha Monk
33
What is Social Prescribing?
https://youtu.be/O9azfXNcqD8
34
White paper 2006: ‘Our Health, our care, our say’
• Focus is in self-management
• Long-term, chronic conditions
• Direct referral from GPs (e.g. exercise on prescription)
• Focus on information to tackle chronic conditions (Expert Patient Programme)
• Community matrons for complex long-term needs
35
Policy interest in social prescribing
• Model for integration across health and social care systems
• One of the 10 high impact actions to release capacity
• Drive to personalize health and social care
• One of the emerging models (Rotherham)
• It was proven to cut A&E, out-patient and hospital admissions
36
Health Inequalities: A wealth of Epidemiological Data
Marmot Review 2010 ‘Mechanisms like social prescribing show signs of empowering individuals to participate and take control of their health and wellbeing (p.155)’
37
NHS 10 Years Plan: good news… • Greater focus on prevention and £20b additional
funding to NHS
• Link workers will work with service users to develop tailored plans and connect them to local groups and support services.
• 1,000 additional trained LWs to in placed by 2020/21.
• Final aim 900,000 people will be able to use Social Prescribing by 2023/24
38
• Public health budget has been cut (NHS, 2019), and corresponding investment to social care and voluntary sector has not increased.
• Who are service users going to be referred to if VCSE is in difficulties?
• Will Local Authorities be able to fund SP if public health
budgets are declining?
• Issues around how Primary Care Networks may commission this
NHS 10 Years Plan: some potential issues…
39
SOCIAL PRESCRIBING AS SIGNPOSTING • Online access to community activities • Direct signpost from GP practice • Emerging evidence base • Leaflet in the GP practice • No link worker SOCIAL PRESCRIBING LIGHT • Run by the voluntary sector to refer people to other activities
delivered by the voluntary sector • To address a specific need of vulnerable patients • No direct links with GP practices
Models of social prescribing (Kimberlee, 2015)
40
SOCIAL PRESCRIBING MEDIUM • Link worker or advanced care navigator • Health focused (nutrition, diet, CBT) • Signpost to voluntary sector and/or self-help groups • Not focused on beneficiary needs in a holistic way SOCIAL PRESCRIBING HOLISTIC • Direct primary care referral to SP provider • SP provider is local and employs link workers • Link worker follows a ‘holistic’ approach (centred
on person’s needs) • No limits on number of sessions. These depend on
person’s need
Models of social prescribing (Kimberlee, 2015)
41
Key elements of Social Prescribing
42
The Bradford story
43
• VCS Summit 2016 • Secured non-recurrent funding (Jan – Dec 17)
• Local Authority contribution
• Commissioning proposal
1. Experience of delivering in Bradford 2. Partnership bids 3. Excellent knowledge of the community and VCS
• Pilot in 26 practices with extensive evaluation
• Collaborative relationship between commissioner/provider
• Secured further investment (Jan 18 – Mar 20)
Commissioning the service
44
45
46
Key Ingredients of Social Prescribing
Taken from: REPORT OF THE ANNUAL SOCIAL PRESCRIBING NETWORK CONFERENCE Wednesday 20 January 2016
47
• Referral pathway – GP’s / Practice staff
• Referral guidelines
• Practices/ Community Partnerships
• SystmOne
• Staff team / Partners
• Training: MHFA / conversations 4 change/ MI
• Regular communication/ peer support/ whats app
• A&E – referral pathway
Hale Community Connectors model
48
• 2017 pilot – 703 referrals - 26 pilot practices
• 2018 a total of 1133 referrals were received for Community Connector support.
• 35 district and 25 city practices
• The service is available to all patients who fit criteria • Out of 162 referrals explored during the pilot, service users were
referred onto 100+ different groups and organisations.
Numbers
49
Better quality of life
Improved individual health and wellbeing outcomes
Improvements in mental wellbeing
Reduced levels of social isolation and loneliness
Improved health behaviours
Improvements in confidence levels, self-esteem and ability to self-care
Better use of Third Sector services
Improved access to non-medical social activities and support
Reduced healthcare resources
Reduced demand on GP services
Reduced demand on urgent care and secondary care services
Improved patient experience
Outcomes
50
• Sheffield Hallam pilot evaluation/ Embed 6 month report
• Most recent evaluation highlights: – Overall, notably more women than men are using the service. – an even distribution of age groups. – Ethnicities of the service users are fairly represented in line with
the 2011 Census
• Five Key measures: Mental wellbeing , Trust, Social Connectedness, Self Care and Satisfaction results all very positive
• The most notable impact was on GP Appointments which saw a reduction of 14%
Evaluation/Impact
51
52
• Funding • Community partnerships • CEE focus • A & E • Ongoing development/ supporting new groups were gaps
identified • Linking in with other Social Prescribing services – sharing good
practice.
New developments
53
•Mrs S had attempted suicide several times and was awaiting a bed to be hospitalised for her mental ill health. •After a short intervention with a community connector Mrs S had met up with people in her local community who she had connected with/ exchanged numbers. She had engaged with the Community Connector and begun to focus on the positive aspects of her life •Mrs S made the decision to remain in her own home, deciding she no longer required this level of intervention. •The Community Connector supported her to access local mental health support in the community. •Mrs S has gone from strength to strength .
84 year old Mrs R had missed many appointments and was struggling. She had become very anxious and nervous She struggled to speak English She also required urgent cataract surgery. • Speaking her own language our Community Connector was able to help her navigate the vast amount of confusing missed/ re-arranged appointments, including her important surgery. She was supported to understand what help was available for her locally to help translate. During the intervention Mrs R had further underlying health needs which she was supported to address promptly. A broken boiler and carbon monoxide testing were also identified and addressed with help.
Please visit the market stall for further details and a vast array of case studies/ newsletter
Stories
54
• Widen referral routes – social care, self referral, group work, link with ABCD funding, community partnerships
• Secure recurrent funding • Refining the evaluation process
• Integrated Care System – more joint work/learning
• Living well programme – align to wellbeing services
• Joint CCG/Local Authority approach
• Personalised care programme – clear linkages
• Evergreen – digital social prescribing
Developing the service
55
• Questions • Opportunities • Sharing learning from other ICS areas
David Cowan
[email protected] Samantha Monk
Questions/group chat
56
1. What can we do together across WY&H? 2. What can we do individually? 3. How do we embed personalised care in our work?
So…
57 57
Lunch & Market Place
Hello my name is… Diane Burke, Head of Public Health – (Long Term
Conditions)-Leeds City Council &
Geoffrey Thorne, Group Secretary Breathe Easy Bramley
www.england.nhs.uk
Matt Simpson and Gill Goodwin Personalised Care Group, NHSE
Personalised Care and Support Planning
Comprehensive Model for Personalised Care All age, whole population approach to Personalised Care
People with long term physical
and mental health conditions
30%
People with
complex needs
5%
Supporting people to stay well and building community resilience,
enabling people to make informed decisions and choices when their
health changes.
Supporting people to build knowledge, skills
and confidence and to live well with their health
conditions.
Empowering people, integrating care and reducing unplanned
service use.
Specialist Integrated Personal Commissioning, including
proactive case finding, and personalised care and support planning through multidisciplinary teams,
personal health budgets and integrated personal budgets.
Targeted Proactive case finding and personalised care and
support planning through General Practice. Support to self manage by increasing
patient activation through access to health coaching, peer support and self management education.
Universal Shared Decision Making.
Enabling choice (e.g. in maternity, elective and end of life care).
Social prescribing and link worker roles. Community-based support.
Plus Universal and Targeted interventions
Plus Universal interventions
Whole population 100%
INTERVENTIONS OUTCOMES
TARGET POPULATIONS
Shared decision making
Social prescribing & community-based support
In 2017/18 SDM was embedded into: • Musculoskeletal elective care
pathways across 13 CCGs • Respiratory elective care pathways in
8 CCGs
• 68,977 referrals in 2017/18 • 331 link workers employed in
local areas
Personalised care and support planning
• 142,904 people had a personalised care and support plan between April 2017 and September 2018
• Over 204,000 people supported by integrated, personalised approaches
Supported self management
Enabling choice
• 97% of CCGs have now completed Choice Planning and Improvement self-assessment
• Of these, 85% report compliance with at least 5 (of 9) choice standards
• 32,341 PHBs by September 2018 • Up 110% year-on -year in 2018 (to end
Q2) • 23% jointly funded with social care • 55,511 Personal Maternity Care Budgets
delivered by September 2018 across 36 CCGs
Personal health budgets & integrated personal budgets
• 101,637 patient activation assessments by September 2018
• Over 44,093 people referred to community-based support
• Over 59,545 people referred to self-management education or health coaching
Significant delivery of Personalised Care
• 86% of people said they achieved what they wanted with their PHB. 77% of people would recommend PHBs to others with similar needs.
• Independent reviews have found evidence that people’s well-being, satisfaction and experience improves through good personalised care and support planning, including for people with cancer.
• 75% of people who booked hospital outpatient appointments online felt they were able to make choices which met their needs.
• People and professionals consistently overestimate treatment benefits and underestimate harms. Shared decision making helps reduce uptake of high-risk, high-cost interventions by up to 20%.
• Local evaluations of social prescribing have reported improvements in quality of life and emotional wellbeing, as well as lower use of primary care and other NHS services. Systematic reviews have found that the quality of evidence is variable and there is a need for more evidence on the effectiveness of social prescribing.
• Personalised care and support planning has been shown to improve GP and other professionals’ job satisfaction.
• Monitoring of costs for PHB holders receiving NHS CHC home care packages found an average saving of 17%.
• An independent evaluation found that PHBs were overall cost neutral. People with a PHB had lower indirect costs through less use of secondary healthcare (average £1,320 per person per year).
• In one site, IPC was implemented at scale alongside other interventions. Following the 100-day challenge in 2017 the site saw a reduction in emergency admissions of 12%, as well as a 24% reduction in A&E attendances for the two practices which took part.
• An independent evaluation found that people who had the highest knowledge, skills and confidence had 19% fewer GP appointments and 38% fewer A&E attendances than those with the lowest levels of activation. This finding was corroborated by a Health Foundation study which tracked 9,000 people across a health and care system.
The difference personalised care makes
To people’s experiences
To people’s outcomes
To the workforce experience
To the system
Emerging evidence
FYLDE COAST Self-management
STOCKTON Care planning
Patient Activation Measure scores increased
by an average of 8.9% following care and support tailored to
people’s needs 24% reduction in
A&E attendances in 2017 within two GP practices
12% reduction in unplanned admissions in
2017 within two GP practices
Across Continuing Health Care, direct savings of up to 17%
NOTTINGHAMSHIRE Personal health budgets
£25,000 saving in transport costs for siblings with very complex health
conditions Lease their own adapted
vehicle through a personal health budget for journeys to day centre and respite,
instead of a commissioned transport package
www.england.nhs.uk
Health improvements included average 10 point increase in EQ-VAS scores
BRADFORD Social prescribing
74% of people increased their mental well-being
after being referred to the scheme
Personal health budgets
Chapter One sets out how the NHS will move to a new service model in which the NHS will increasingly be: more joined-up and coordinated in its care; more proactive in the services it provides; more differentiated in its support offer to individuals.
It sets out five major, practical, changes to the NHS service model to bring this about over the next five years: • 1. We will boost ‘out-of-hospital’ care, and finally dissolve the historic divide
between primary and community health services. • 2. The NHS will redesign and reduce pressure on emergency hospital services. • 3. People will get more control over their own health, and more personalised
care when they need it. • 4. Digitally-enabled primary and outpatient care will go mainstream across the
NHS. • 5. Local NHS organisations will increasingly focus on population health and local
partnerships with local authority-funded services, through new Integrated Care Systems (ICSs) everywhere.
65
The NHS Long Term Plan Chapter 1: A new service model for the 21st century
What does this entail?
Roll out the Comprehensive Model for Personalised Care across England, reaching 2.5 million people by 2023/24 and aiming to reach 5 million people by 2028/29 (para 1.39)
Component Goal by 2023/24
Shared decision making Shared decision making embedded in 30 high value clinical situations in primary care, secondary care and at the primary/secondary interface where it will have the greatest impact on experience, outcomes and cost
Personalised care and support planning 750,000 people with long term conditions
Enabling choice, including legal rights to choice Legal rights to choice are maintained throughout wider system transformation, with 100% of elective referrals exercising choice through the electronic Referral System and 100% of CCGs compliant with choice improvement guide
Social prescribing and community-based support
900,000 people referred to social prescribing link workers
Supported Self-Management Continue to increase the opportunities for people to benefit from supported self-management approaches
Personal health budgets and integrated personal budgets
200,000 people benefitting from PHBs or IPBs
Specific Personalised Care commitments in LTP
• Provide people with a wide choice of options for quick elective care, including choice at point of referral and proactively for people waiting for six months (para 3.109)
• Use decision-support tools to augment the ability to deliver personalised care (para 3.106), and ensure the least effective interventions are not routinely performed, or only performed in more clearly defined circumstances, potentially avoiding needless harm to people and freeing up scarce professional time (para 6.17viii))
• Put in place over 1,000 trained social prescribing link workers by 2020/21 and over 900,000 people referred to social prescribing link workers by 2023/24 (para 1.40)
• Ramp up support for people to self-manage their own health (para 1.38) • Accelerate the roll out of Personal Health Budgets to give people greater choice and control over how care is planned and
delivered. Up to 200,000 people will benefit from a PHB by 2023/24 (para 1.41) • Support and help train staff to have personalised care conversations (para 1.37)
www.england.nhs.uk
What does good personalised care and support planning look like?
69 Its about a different conversation, starting
from a different place….. and
There are 2 key principles to personalised care and support planning….
……. seeing people as equal partners in the process
Personalised Care and Support Planning – Key features
Perspective – this is a way of ‘seeing people’ and attitude towards them that is fundamental to good Personalised Care and Support Planning. The changed relationship and different conversation will mean that the person: • is empowered and builds knowledge, skills and confidence • experiences hope and feels confident that the process and the plan will deliver what matters most to them • is central in developing their Personalised Care and Support Plan and will agree who is involved. • is seen as a whole person within the context of their whole life, valuing their skills, strengths, experience and important relationships • is valued as an active participant in conversations and decisions about their health and well being.
Personalised Care and Support Planning – Key features
Process – this is the overall process of personalised care and support planning A good Personalised Care and Support Planning process will mean that the person: • has the time and support to develop their plan in a safe and reflective space • is able to access information and advice that is clear and timely and meets individual information needs and preferences • feels prepared, knows what to expect and is ready to engage in planning supported by a single, named coordinator • is listened to and understood in a way that builds trusting and effective relationships with key people • is able to agree the health and well-being outcomes* they want to achieve, in dialogue with the relevant health, education and social care professionals • has the chance to formally and informally review their personalised care and support plan * and learning outcomes for children and young people with education, health and care plans.
Personalised Care and Support Planning – Key features
Plan – this is what a good plan looks like A Personalised Care and Support Plan: • is a way of capturing and recording conversations, decisions and agreed outcomes in a way that makes sense to the person. • should be proportionate, flexible and coordinated and adaptable to a person’s health condition, situation and care and support needs. • should include a description of the person, what matters to them and all the necessary elements that would make the plan achievable and effective.
www.england.nhs.uk
Understanding and sorting Important To & For
www.england.nhs.uk
“The quality of our lives depends on the presence or absence of things that are important to us” Michael Smull
for
Health and safety can dictate
Health and Safety dictate life
to
all choice no responsibility
All choice: No responsibility
. What is important to a person includes only what people are “saying”: -with their words -with their behaviour When words and behaviour are in conflict, listen to the behaviour.
Important to
. .
Important for
This includes only those things that we need to be mindful of regarding issues of health or safety and fulfilling potential. Think about…….. How best to support … to be healthy and safe What others need to know or do …
Hello my name is… Diane Burke, Head of Public Health (Long Term
Conditions) &
Louise Cresswell, Health Improvement Principal (Long Term Conditions)
Public Health, Leeds City Council
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Personalised Care and Support
Planning in Leeds
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Population of 751,485
There are 164,000 people in Leeds who live in areas that are ranked amongst the most deprived 10% nationally.
10 year life expectancy gap between the most deprived and most affluent areas
There are 141,771 people from BAME communities (19%) and over 85 languages spoken
99 GP practices; 1 CCG within
Leeds with different boundaries to LCC locality working
Leeds
People in the Population Health Management of Long Term Conditions cohort (n=292,000)
Grouped by age band and count of long term conditions in Leeds
Data Extracted from GP Clinical systems 2018.
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Attributable costs to LTC’s in Leeds (October 2018)
48% of all activity through the Health care system is for people living with LTC’s
47% of the overall budget
27% of all GP appointments
24% of all inpatient costs
Leeds Health and Wellbeing Board
In Leeds we believe wellbeing starts with people: The connections,
conversations and relationships between services and citizens and
between people in their families and communities have a huge impact on
us all.
Quality conversations make a difference, especially when used
positively by services to work ‘with’ people to find solutions rather than things being done ‘to’ people or ‘for’
them.
Our commitment to working with people is about bringing these beliefs to life, by
developing the skills and mind-set across Leeds’ health and care workforce to use
solutions that work with people wherever it is safe, appropriate and the right thing to
do.
Working ‘with’ means…
Better conversations: A whole city approach to working with people Focus on
‘what’s strong’ rather than
‘what’s wrong’
Actively listen to what
matters most to people
Start with people’s lived
experience
Put people at the centre of all decisions
Work as partners to
achieve individual
goals
Be ‘restorative’. Offer high
support and high challenge
Build on the assets in
ourselves, our families & our communities
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Enabling Systems and Processes
Engaged Informed Person
HCP committed to partnership
working ‘working with’
Commissioning and Involvement
Digital systems/ records Workforce systems – menu of training options
Neighbourhood asset based approaches – Better Together. West Yorkshire & Harrogate Health Care Partnership Personalised Care
Demonstrator Site - 2018/19
CCSP Better Conversations
PAMS Making Every Contact count Strength based Social Care
Digital Solutions Peer Support groups
Personal Health Budgets Structured/flexible
education programmes Leeds Directory
Social Prescribing Structured education Peer Support plan
Coproduction
Shared Decision making
The Leeds House of Care
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Hours with healthcare professional
= 4 hours in a year
Self-management
= 8756 hours in a year
Long term conditions are different
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• It is firstly about making routine consultations between clinicians and people with long term conditions truly collaborative, through care-planning - changing the relationship
• then about ensuring that the local services people need to support this are identified and available, through commissioning – changing support for self management
• It is not just about tools and structures, that it’s mostly about the relationship between the health care professional and person, an individual’s philosophy will determine how they communicate, work with and value patients contributions.
This creates an opportunity for people to feel more in control of their health.
Collaborative Care and Support Planning
Leeds Health and Wellbeing Board
This involves people, with a long term
condition(s), working with those delivering their care to make joint decisions and
agree how their long term conditions will be
managed.
One of the key elements is sharing the results of annual
checks, so that people with a long term
condition(s) have a chance to think about
their results before their Care and support Planning appointment.
Information Gathering
Information Sharing
Consult and joint decision
making. Agreed shared goals and action plan
1st Visit Between Visits 2nd Visit
During the annual review process
Disease surveillance
Tests and checks
performed where
needed
Preparation Results/ agenda setting
prompts sent to patient
> 1 week before
conversation
Conversation
A meeting of equals and experts
Prepared practitioner and patient:
review how things are going consider what's important
• share ideas • discuss options
• develop a care plan • Agree on goals
‘A Collaborative Care and Support plan is at the heart of a partnership approach to care and a central part of effective care management. The process of agreeing a care plan offers people active involvement in deciding, agreeing and owning how their condition is to be managed’
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• Collect useful and important information
• Be clear about the two appointment process and receiving the results
• Time between appointments allows for time to consider what people wants to get out of the consultation
• Take time to think and talk with other people what matters most
Prepared and Informed people
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Care planning – it’s a verb
‘A care plan is at the heart of a partnership approach to care and a central part of effective care management. The process of agreeing a care plan offers people active involvement in deciding, agreeing and owning how their condition is to be managed’
Partnership working
Individual patient choices via the care planning process = micro-level commissioning
Individual choices & population care MENU OF OPTIONS: Examples
Support for Self management
• Patient Education
• Weight management
• Smoking cessation
• Better Conversations
• Exercise programmes
• Health Coaching sessions
• Community support: Buddying / walking groups…
• Tele care
• Social prescribing
• Leeds Directory
• Personal Health Budget
• Forward Leeds
• Peer Support
Coordinating clinical / social input
Population level decision making and service delivery based on actual needs of individuals
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• Implemented in all 99 GP Practices • 65,515 people have had a annual review
using the CCSP approach (April 18 - Dec 18)
• Over 600 HCP have attended the training
Current picture
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Impact Data for Leeds CCG, National Diabetes Audit (T2) (95% of practices)
Attainment of measure 2016/17 2017/18
Type 2 Diabetic patients receiving
all 8 care processes* 49.30% 66.40%
*Data from the National Diabetes Audit. The England average for all 8 care processes in 2017/18 is 58.8% (8 care processes are HbA1c, Blood Pressure, Cholesterol, Serum Creatinine, Urine Albumin, Foot Surveillance, BMI & Smoking
Our Journey
6 GP practices early implementors - Evaluated by LBU
2014
2013
2015
2017
Monthly workforce training sessions
YOC – Nesta quality assured train the trainers
Secured CCG funding for city wide roll out
Developed City wide template
PC Facilitator post to embed in practice
Recruited GP champions
In House – taster sessions 2016
Developed Practice manager & Admin training
436 staff trained
2018
CCG Merge
Template review
Half day training developement
Included within QIS
Embeded trianing within BC
Sustainable model of training
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• Senior leadership buy in • Quality Improvement Scheme • City wide approach – train the trainers • Primary care facilitator • GP buy in • Clinical Template for consistency/data
quality • Funding • Culture change – Workforce
Enablers
100
• Different approaches across the city (3 CCGs)
• Reliant on good will – Training • Disengaged GP practices • Clinical template • Evidence – outcomes
Challenges
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Next Steps - system • Helm – Person Held Record • Quality improvement to understand the
requirements of sharing the care plan and clinical information across Health & Social care organisations
102
• Commissioned insight work – Results, goals, conversation
• Patient Engagement group • Coproduction – personalised care. • ‘What matters to me’ – Person Centred Care Plan
Next Steps - working with people with lived experience
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Personalised Care & Support Planning What is happening in Places and how you can find out more
Bradford Calderdale Harrogate Kirklees Leeds Wakefield PCSPs for PHB are in place. People with long-term conditions have Personalised Care Plans
LOTAs have been introduced for children with life limiting conditions at CHFT
Educational & Health Care Plans (EHPs) for children in place. Patients with MH or LD all have care and Treatment Review plans in place.
GOMPs in place within community services. Learning Disability Personalised Care process Defining a consistent approach to personalised care planning across Kirklees.
Train the trainer programme in place. CCSP has continued within the city. Embedding the approach of ‘better conversations’, all GP practices are now engaged in this process.
Education and Health Care Plans and Care plans in care homes to be holistically driven with an emphasis on Advance Care Planning for care homes for 65`s in Wakefield.
Bridget Jones [email protected]
Sarah Antemes [email protected]
Paula Middlebook [email protected]
Rachel Millson [email protected]
Diane Burke [email protected]
Pam Sheppard [email protected]
Discussion and Questions
Question:
• What can we do together across WY&H?
• What can we do individually? • How do we embed personalised care in
our work?
Hello my name is… John Walsh, OD Lead,
Leeds Community Healthcare NHS Trust &
Alyson McGregor, Director Altogether Better
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Collaborative Practice is a new way of organising • Deals with the things that medicine cannot fix
• Supports staff to work collaboratively
• Practices understand and use their data to make better decisions
• Invite local people to gift their time to coproduce new solutions
• The new extended team/family develop a range of new offers • Clinicans & staff connect patients to new offers
• Meets demand and reduces pressure
• It’s BETTER FOR EVERYONE
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“ coming along has turned the lights back on for me”
The relationship determines the outcome
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1 + 1 = 2
Alyson McGregor: 07780593409 John Walsh:07960828285
e: [email protected] [email protected]
@al2getherbetter @johnwalsh88
altogetherbetter.org.uk
Join our workshop or chat to us
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Workshops
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Shared Decision Making Sarah Antemes
Place Lead for Calderdale
Format of the workshop
Topic Presenter Time
Introduction Sarah Antemes 13:55
Shared Decision Making (SDM) – Context and Impact
Surfraz Ahmed Pauline Grant
14:00
Experience of adopting SDM within LCH MSK service
Steve Laville 14:10
Shared Decision Making in the Calderdale Staying Well programme
Vicky McGhee Rachel Swaby
14:25
Shared Decision Making in Calderdale Healthy Minds
Jonny Richardson Glenn 14:40
Conclusion Sarah Antemes 14:55
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Introduction
Sarah Antemes – Place Lead for Calderdale • Purpose • Presentations • Opportunity for questions and answers
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Shared Decision Making: A different conversation…
Pauline Grant Deputy Policy Lead Shared Decision Making and Health Literacy Saf Ahmed Policy Officer Shared Decision Making and Health Literacy 25th February 2019
@ThePaulineGrant @SurfrazAhmed
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Shared Decision Making
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Clinicians
Patients
Together they make a decision
• Best evidence
• Clinical expertise
• Patient expertise
• Individual patient preference
Conversation between
equals
Why is SDM important?
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It can create a new RELATIONSHIP between individuals and professionals based on partnership (Mulley et al, 2012).
People want to be more INVOLVED than they currently are in making decisions about their own health and health care (Care Quality Commission inpatient survey, 2016; NHS England, GP survey. 2017).
Both individuals and clinicians tend to consistently OVERESTIMATE the benefits of treatments and UNDERESTIMATE the harms (Hoffman, 2017).
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Why is SDM important?
• .
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It has the potential to ENHANCE allocative efficiency and REDUCE unwarranted clinical variation (Mulley et al, 2012).
It is a LEGAL requirement and health professionals now must take “reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment and of any reasonable alternative or variant treatments”.
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When is it appropriate?
Reduction in referrals and reduced spend
• In Bedfordshire 35% of patients having an SDM discussion choose alternative options to surgery resulting in a 24% reduction in Secondary Care referrals.
• Pennine MSK Partnership reported that
Arthroscopies grew at 8% in Oldham compared to 12% nationally and Musculoskeletal spend per head decreased by £10 in Oldham compared to an increase of £10 nationally.
Improving efficient use of services
And what about health literacy?
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43% - 61% of English working age population do not understand health information they are given (Institute of Health Equity/Public health England 2015)
There is a strong social gradient in the population, with lower levels of health literacy much more common among the socially and economically disadvantaged ie it impacts on health inequalities.
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What good shared decision making looks like for the system
133
Another way to share decisions(!)
134
Experience of adopting SDM within LCH MSK service
Steve Laville Senior Commissioning Manager
NHS Leeds CCG
Why adopt SDM?
• Proposal was originally made by NHS LSE CCG clinical leads
• Objective - better informed decisions o Realistic expectations o Confidence that the right choice has been made o Reduction in overtreatment
• Improved patient experience
• Improved patient outcome
Where to adopt SDM • Situations where patients are faced with
preference sensitive choices
• Additional element of existing pathway step – Not additional pathway step
• Where we could realistically assess its impact
• NHS Leeds Community Healthcare MSK service
How we introduced SDM • Initial engagement between CCG Commissioners, and LCH MSK service clinical leads and managers
• Extensive external SDM training delivered – commissioned by the 3 Leeds CCGs
• MSK Service wide strategy for dissemination :- o Policy adopted that all patient facing staff receive appropriate training o All patients are provided with information outlining the support they will
receive, and asked to prepare any questions they may like to ask in advance
• GP comms exercise
• Programme Launched April 1st 2015
Specific project objectives
1. To ensure that in all situations where a patient faced preference sensitive treatment options, the patient would be supported in making this decision through a structured SDM process
2. To measure how well supported patients felt in
making their treatment decision 3. To measure the outcomes of the SDM discussions – in
particular, how many patients opt for orthopaedic opinion with a view to considering surgery
• Between April 15 – February 16, 2,531 SDM discussions were read coded
• Service Clinical Lead also confirmed that the SDM training had been highly valued by all the practitioners who received the training
• Did mark a cultural shift – informing all consultations
• Shift away from prescriptive or directive provision of care, to
a more inclusive approach
What Happened – Objective 1 Patients being supported in decision making through a structured SDM Process
What Happened – Objective 2 How patients felt about SDM • Independent monthly telephone follow-up carried out by Leeds
Involving People • Low take up, but the responses that were given were
overwhelmingly positive • 114 responses – on a score of 0 (terrible) to 9 (outstanding)
o 101 patients scored 8 or 9 to the question “How much effort was made to understand your health issues?”
o 101 patients scored 8 or 9 to the question “How much effort was made to listen to the things that matter most about your health issues?”
o 100 patients scored 8 or 9 to the question “How much effort was made to include what matters most to you in choosing what to do next?)
What Happened – Objective 2 How patients felt about SDM
Summary of Patient Views Yes No N/A
Did you feel sure about the best choice for you? 104 9 1
Did you know the benefits and risks of each option? 104 9 1
Were you clear about which benefits and risks matter most to you? 104 9 1
Did you have enough support and advice to make a choice? 105 8 1
MSK Discharges to orthopaedics and spinal surgical services
5800
6000
6200
6400
6600
6800
16/17 17/18 18/19
4600470048004900500051005200530054005500
14/15 15/16
What happened – Objective 3 Comparative outcomes following SDM discussions
Lessons Learned/Points to Consider • Lots of people think that they routinely deliver SDM, when
actually, they don’t. (Unless you have been specifically trained to do it, you probably don’t do it)
• High quality training was really valuable
• It cannot just be dropped into the pathway – it has to be a culturally integrated element of how services are provided, at every stage of the pathway
• It has to be swallowed whole – requiring strong leadership and credible clinical champions
• Manage the message! It is all about paying attention to improving people’s lives on their terms.
• Really, there is no excuse for not doing it.
Shared Decision Making is a collaborative process aimed achieving an optimal outcome
Clinicians
• Clinical knowledge • Treatment options • Benefit and risk
Patient
• Person-specific knowledge • What is important to them • Appetite for risk
Shared decision making
discussion
Plan to achieve optimal
outcome
Overtreatment Be very careful in how you use this term! • It is not about cutting costs. • It is about making sure that patients receive
treatments that best match their objectives and expectations.
• Preventing overtreatment means preventing patients from receiving treatment where the harms have outweighed the benefits.
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Shared Decision Making in the Calderdale Staying Well Programme
Vicky McGhee & Rachel Swaby
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A Staying Well key worker meets
the person and discusses ways to
improve their quality of life and
wellbeing.
The Route to Wellbeing: the Staying Well model Staying Well is social prescribing service for Calderdale.
Adults are referred to Staying Well
through a variety of sources
Promotes independen
ce
Expands horizons
Person Centred
Flexible
Underlying Principles
Social Care
NHS
GPs
Friends and Family
Community Groups
Self referral
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The Route to Wellbeing: the Staying Well model Staying Well is social prescribing service for Calderdale.
Options available to an individual include
New social activities funded
Access to other formal
services
Continuing support
Linking to a community
activity
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“When you make someone a cup of tea,
especially a proper cuppa in a teapot,
you’re saying, ‘here is some of my time,
we can chat if you want to but I’m
going to make you a brew and drink it
with you’”.
Helen, Staying Well Worker
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Shared decision making at all levels
Calderdale Council
Strategic Delivery Group
Local Steering Groups
VCS Anchor Organisations
Staying Well Workers
Person
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Shared Decision making in Healthy Minds
Jonny Richardson Glenn
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Welfare / benefits
Debt Volunteering
Roshani: BAME mental health
10 -19 years
Recovery Courses & Workshops
Anxiety Anger
Confidence Creativity Mood
Loneliness Assertiveness
Out-of-hours crisis support
Employment support
Peer Support Groups
Allotment Walking
Janet
Long history of MH problems
Difficulty accessing NHS MH services
Professional role: stigma
Despair
Exhausted ‘usual’ avenues
Isolated
Janet
Long history of MH problems
Difficulty accessing NHS MH services
Professional role: stigma
Despair
Exhausted ‘usual’ avenues
Isolated “Through Healthy Minds I have not just learnt skills and techniques to help me manage my conditions, but to do so without fear of judgement, amongst an understanding community. Nowhere else have I experienced this extra step of real-world practice. They just get what I need.”
Out-of-hours crisis support
Employment support
Peer Support Groups
Allotment Walking
Recovery Courses & Workshops
Anxiety
Anger
Confidence
Creativity
Mood Loneliness
Assertiveness
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Conclusion Sarah Antemes
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Coffee break
Hello my name is… Ian Holmes – Director, West Yorkshire and
Harrogate Health and Care Partnership
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Q&A panel
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Next steps
Close and Networking
Further information
• Visit www.wyhpartnership.co.uk • Weekly blog www.wyhpartnership.co.uk/blog • ‘Our Next Steps’ www.wyhpartnership.co.uk/next-steps • Follow: @wyhpartnership