Community Wellbeing Service

Descriptions

Overall, 16.2% of Southampton's population have at least one Long Term Condition (LTC). The proportion of people with LTCs increases with age, as does the proportion of people with multiple LTCs. There are currently 35,593 people living in Southampton who have three or more chronic conditions and the ageing population will see this increase in the coming years. However, in Southampton this situation is not confined to the elderly, indeed in an analysis at the beginning of this contract people who experienced more than 3 admissions to hospital in that year, 64% were found to be in the age band of 19-64. By 2038 it is estimated that the number of Southampton residents who have three or more chronic conditions will have increased by nearly 20% to 42,509. , The key aims of the CWS service are to:, •Reduce the need for acute, urgent and long-term care by proactively identifying those at risk earlier, to ensure the correct support is in place in a timely way. , •To promote this approach by being part of a wider network of health, care and wellbeing delivery across the city. , The prevention agenda underpins part of the Southampton Health and Care strategy (2020-2025) and forms key elements of the national Ageing Well Programme, which promotes people being able to live more independently for longer, identifying unknown carers and bringing together other professionals to help coordinate better care. , Solent Medical Services Ltd (SMS) who currently provide the service is an NHS-staff owned company, established in 2007 to provide community care services to Southampton GP registered NHS patients. , The current contract for the CWS was awarded to SMS Medical following an open competitive tender process on the 1st April 2017 on a 3 year plus 2 year option to extend, contract term. Currently in the extension period, the contract is due to expire 31st March 2022. , The contract value is £1,197,740 per annum .SMS have delivered a proactive and responsive service offering good patient experience and outcomes. The service have developed a strong collaborative working relationship with the CCG and other providers across the city from: social care; primary care; community nursing; the voluntary sector; social prescribing provider; and the local acute hospital Trust. They have been flexible and adaptable during the pandemic by supporting other services particularly where the patients who were shielding (Clinically Extremely Vulnerable) are concerned. The service also rolled out the Covid-19 vaccination to housebound and shielding patients in Southampton. SMS Medical have a CQC rating of 'good' following an inspection in August 2018. Patient and referrer feedback is positive., The service is working with other providers, such as Southern Health NHS Trust, to carry out pilots on some of the hardest to reach members of the population, including those on the serious mental health register and people who smoke., A new national programme of work for the Ageing Well agenda is due to be released in 2021, which will provide further detail and direction regarding the planning and delivery of prevention work. This will need to be taken into account in relation to the service and the future direction of travel for this area of work in the coming years. , On 1 April 2021, the Hampshire, Southampton & Isle of Wight CCG were legally formed and subsequently there will be work to undertake to prepare for the ICS structure changes currently going through legislative process. The new CCG will need to take stock of all services across the new geography, in order to ensure a seamless transfer to the ICS system, without disruption and clinical risk to patients., Patient need, experience, quality and efficiency:, At the beginning of the contract, SMS carried out an analysis of the Public Health Joint Strategic Needs Assessment tool for Southampton, which enabled them to identify the areas of the city that have the largest unmet needs. The analysis showed that the following cohorts were to be targeted by the service:, •People/adults living with Long Term Conditions , •Adults with multiple long term conditions and do not engage with their GP Practice - this may include people living with a Serious Mental Illness or Learning Disability, •Adults who have multiple admissions to acute services and not known to the GP Practice, •Adults who are within the 20% risk of admission to acute care and who are not already under the care of community services., SMS have delivered high quality and good value care, which is delivered in a timely way through working in GP Practices and carry out home visits where needed. This is evidenced by performance against KPI's in the contract., The proactive element of the service means they are able to identify and target those who are hard to reach and who are not engaging with their GP or other health services. The preventative part means the service build up relationships with individuals to create trust and a feeling of safety, so that often they are more likely to engage with other services that they may need. , Patient feedback on the service provided is positive and where appropriate the provider responds to this feedback in a similar manner with their patients. , Proposal:, Direct award to SMS Medical for a period of 12 months + 12 months (1st April 2022 to 31st March 2024) at a total cost of £2,395,480, Rationale for Direct Award: There are multiple factors which have a bearing on future planning regarding prevention and proactive care. The CCG need additional time to be able to look at the following area's in order to better plan what this agenda will look like going forward and for the future of the service. , •Changing context - new prevention and anticipatory care requirements being set out by NHS E&I, in particular through the Ageing Well Programme, expected to be published in Q3 or Q4 2021/2022, •The further development of social prescribing infrastructure, that is evolving across primary care and wider, meeting some of the lower level need within the city., •The challenges faced by people living in the most deprived areas of the city, noting that deprivation in relative terms is increasing and with it demand for increase in preventative work. , •Change in patient demand - particularly following the Covid pandemic and how this has affected the population need in Southampton., •Looking and assessing the service against the new CCG geography and to ensure a seamless transfer to the ICS system, without disruption and clinical risk to patients. , •Evaluation of impact of preventative care best practice examples suggests that reduction in intensive resource use is not seen until 4 - 6 years from the intervention. (NHS and Solution for Public Health, 2021), The benefits of remaining with the current provider are:, •Consistency in service provision in keeping the current provider. SMS are known and trusted by patients and have well-established clinical relationships across the system including GPs, and the acute Trust., •SMS are performing well as a provider as evidenced by their KPI's and quarterly reporting to the CCG, •Known service that has already shown it can be flexible as we move into the uncertain future of a surge in demand for all community services., •Current provider can maintain and build upon existing relationships with other providers and services., •The changing landscape offers many opportunities, but in the short term means there is a level of uncertainty around longer term delivery models and requirements, such that it is not possible to confidently specify requirements from the CWS, •Enables a substantial opportunity to re-evaluate the current patient demand in Southampton that falls under the prevention and proactive care remit and redesign where necessary along with the aforementioned programmes of work. , •Maintain stability in the medium term, to ensure the best possible outcomes and experience for our patients., •Benefit from established clinical relationships that have already fostered confidence in service delivery., •Support patient confidence, with a provider already known to local patients.