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Our plans to achieve integration at locality level

There is general recognition at both a national and local level that communities are the engine house for delivering transformation. If we are to achieve the changes we need to make in order to realise our vision, the planning and delivery of services must take place as locally as possible.

Edinburgh is a diverse city with many different communities of both geography and interest that have varying levels and types of needs in terms of health, social care and wellbeing. In many cases, these are needs that can best be addressed by a range of services, not simply those that are the responsibility of the statutory health and social care agencies. Indeed the most effective way of meeting some needs, loneliness for example, may lie with communities themselves. It is for these reasons that the Edinburgh Health and Social Care Partnership, along with the Edinburgh Community Planning Partnership, the City of Edinburgh Council and NHS Lothian believes that it is right to shift the focus of our service planning and delivery to localities. This will involve working in partnership with and empowering local people and communities, improving the co-location and integration of services and devolving budgets and decision making closer to the point of service delivery.

To achieve this, the organisations that belong to the Edinburgh Community Planning Partnership have agreed that all partners will adopt the same four geographic locality boundaries as the basis for service planning and delivery in the city. The four localities are based around the existing twelve Neighbourhood Partnerships as detailed in the table below and shown on the map on the following page:

Locality Neighbourhood Partnerships PopulationNorth West Almond, Forth, Inverleith and Western Edinburgh 138,995North East Leith, Craigentinny/Duddingston and

Portobello/Craigmillar110,550

South West Pentlands and South West 111,807South East/ Central City Centre, South Central and Liberton/Gilmerton 126,148

Total 0

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A brief profile of each locality is given on pages 19 and 20 of the draft plan, should this be moved to an appendix or left out of the final plan?

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Bringing health and social care service providers together to work as integrated teams to meet the needs of people and communities is the core purpose of the Partnership. To achieve this we have put in place a locality management structure to lead these four areas as the expected delivery level for most front line services to citizens.

From April 2016 we will ensure that local health, social care, voluntary and independent sector care providers, along with carer and service user representatives and other local organisations, are able to work effectively together by establishing local collaborative working arrangements, under the leadership of the Health and Social Care Locality Managers. In addition to those directly involved in delivering health and social care services and support, links with the housing sector, including social housing landlords, will be strengthened to ensure people’s needs for a warm, affordable and accessible home can be met, and people can live independently as far as possible.

We have included actions within the flow of the text and propose to indicate that they are actions by putting them in boxes, does this work or would it be better to list all actions at the end of each section, alternatively we could do both?

The use of common boundaries across partners provides excellent opportunities to integrate service planning and provision not only across health and social care, but across all agencies. A transformation programme is currently underway within the Council, aiming to integrate services such as housing, services for communities, children and families etc (others??) at a locality level and similar changes are being considered by police and fire and rescue services. Edinburgh Health and Social Care Partnership locality staff will be core participants in new locality teams being established by the Council, and effective joint working with council services and other partners in community safety will be vital to help deliver our priorities, in particular greater focus on prevention, early intervention, and tackling inequalities.

The move to working at locality and indeed below this at neighbourhood level will enable all partners to build on local knowledge and connections to foster the healthy neighbourhoods and resilient communities that respondents to our consultation on the draft strategic plan told us they want to see. We will however ensure that equitable access to services is maintained, so that “post-code lottery” variation in support does not develop in different parts of the city. There will of course continue to be services where the dispersed community of interest or limited specialist facilities make it more sensible to plan and deliver services at a city wide level.

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Providing staff with the opportunity for more local engagement is also anticipated to support the culture change in our services which many people have identified is needed. We say more about the approach to workforce development in section xx.

Locality managers will work with staff teams to empower staff to work more flexibly to seek solutions and avoid unnecessary “hand-offs” to another team or service, with the aim of providing more seamless and responsive care and support when needed.

A priority action for the Partnership is to develop access hubs within each locality coordinating community resources more effectively in order to:

maximise support for independent living reduce the need for admission to hospital; and support timely discharge from hospital

An access hub has already being piloted in South East/ Central locality during the winter of 2015/16 and the learning from this shared across the city. Close working with hospital based staff has been established and existing staff teams are being supported to work more flexibly to develop timely plans to meet people’s increased needs at home where possible. When individuals are admitted to hospital information on their care needs is being shared at daily reviews and joint plans developed to allow people to return home with support as soon as their acute care needs have been met.

We recognise the vital role General Practitioners already play in providing and co-ordinating care at local level, and the increasing needs and demands which are managed by practice teams and wider community staff groups.

Learning from the House of Care and Headroom GP practices which are piloting approaches to support a culture of person centred care and support will help us develop effective models of local team working, linking people to local community resources and wider supports which can foster positive health outcomes. We will also build on the learning from the Total Place pilots which

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are bringing together local services and resources around the needs of local people to improve individuals’ opportunities and outcomes in Wester Hailes, Craigroyston and elsewhere.

We will support the development of integrated health and social care teams based around GP practice clusters within the four localities to support more flexible ways of working with a focus on prevention, early intervention, anticipating and planning for care needs.

Locality health and social care management teams will be supported to further understand and plan, in collaboration with partners, for the needs of each locality as we develop the initial Joint Strategic Needs Assessment during 2016, adding greater local detail. This will allow the development of the first set of health and social care locality plans by April 2017, which will feed upwards to update the next version of this Strategic Plan, inform the Community Planning Partnership Locality Plans, and in turn directly influence plans for resource use across the NHS and Council by identifying relative need between and within localities.

In the partnership’s performance report on its first full year of operation the extent to which these actions have been successful in progressing locality working and engagement will be reviewed.

How can we best illustrate the impact of these changes on citizens, i.e. how will they see a difference?