Report of York Health and Care Collaborative


October 2020


1.    Introduction


This report provides a briefing on the following;


·         The background to the establishment of the York Health and Care Collaborative (YHCC)

·         The role of the YHCC in the context of the Joint Health and Wellbeing Strategy and the NHS Long Term Plan

·         The purpose, scope and ways of working for YHCC

·         Strategic priorities for 2020/21 and progress to date, including impact of Covid-19

·         Future work and further development of the York Health and Care Collaborative.


2.    Background


York Health Care Collaborative (YHCC) was established in January 2020 and is the successor to the Primary Care Home Steering Group, which was set up in 2017 to implement the “Primary Care Home” model in York. This was aimed at improving collaborative working across; primary and community care, physical and mental health services, health, social care and the voluntary sector, focusing on population needs to develop ways of providing better coordinated services, by putting the person at the centre of care. These aims remain central to the work of YHCC, which has been able to build on this foundation and further develop this approach.


3.    Context


This is in line with local and national strategy, both the implementation of the Joint Health and Wellbeing Strategy for York and achieving the objectives of the NHS Long Term Plan (a strategic priority for all NHS organisations) are reliant on effective collaboration. As an effective multi-agency group, YHCC is well placed to foster improved collaboration and the development of integrated services for York.  


4.    York Health and Care Collaborative;purpose, scope and ways of working


·         The role of Primary Care Networks


The development of community-based services based on strong partnerships between health, social care and the voluntary sector that engage local communities is a key strategic priority of the NHS Long Term plan.


Primary Care Networks (PCN) established in in March 2019, each serving a population of c50,000 are seen as the cornerstone for the development of closer collaboration at a local community level in line with this ambition.


·         Configuration of PCN in York


York is relatively unusual in that there are a number of large practices, with branch surgeries across the city, each with a list size of c50,000 which were able to form PCN without the need to network with other practices, consequently the five PCN that were established in York have a city-wide “footprint”.


The Clinical Directors are fully committed and supportive of YHCC and the Collaborative is chaired jointly by two of the PCN Clinical Directors as YHCC is the way that PCN in York “network” with partners achieve the vision Long-Term Plan for York.  


·         Guiding Principles


In line with these ambitions, the purpose of the York Health and Care Collaborative is summarised as follows;


to build on the strengths and assets of the local community and the collective capability of member organisations in order to enhance the outcome and experience of care for people, in line with the principle that care and support should be well coordinated and person-centred.


·         The role and membership of the Steering Group


The work of the YHCC is led and coordinated by the Steering Group, whose role is to understand the health and care needs of the population, identify strategic priorities and develop and oversee an annual work programme. 


Membership of the Steering Group is drawn from the following organisations;

·         York Primary Care Networks

·         Nimbus Care

·         York Teaching Hospitals NHS FT

·         Tees Esk and Wear Valleys NHS Foundation Trust.

·         City of York Council – Public Health

·         City of York Council – Social Care

·         Vale of York CCG

·         York Centre for Voluntary Services

·         Healthwatch York


Extended membership includes organisations/sectors that provide health and/or care services to the population of York.


The Steering Group recognises the importance of public and patient representation in all aspects of the its work and there is a Lay Representative as a core member of the Steering Group and all sub-groups actively consider how to effectively and appropriately engage the public and patients in the work that is undertaken.


As a “member organisation” there is no delegated decision making from member organisations; to be effective the Steering Group relies on members reaching decisions by consensus.  


5.    Strategic Priorities 2020/21


The following priority areas were identified at a multi-agency workshop in February 2020, using population health intelligence as the basis for identifying priority areas. 


Strategic Priority

What is the rationale/evidence?

How does this link to national local/priorities?

Prevention; focus on

Although all national issues, specifically, in most deprived wards, there are problems with; 

·         Smoking in pregnancy

·         Alcohol consumption (under 15s)

·         Childhood obesity.

In addition;

·         Below national average but over 50% adults obese 

·         Alcohol related hospital admissions.  Higher rate than average (national, local, peer)

NHS Long Term Plan


York Health and Wellbeing Strategy/ JSNA

·        Substance misuse

·        Smoking

·        Obesity

·        Type 2 Diabetes

Ageing Well, frailty and multi morbidity

Age and deprivation profile

·         Relative wealth masks areas with higher than average deprivation: correlation between poor health outcomes and multimorbidity/deprivation.

·         Need to support older people in the community and especially the growing Care Home and Nursing Home population more effectively and collaboratively.  

·         Dementia diagnosis lower than peers.

NHS Long Term Plan


Operational Planning and Contracting Guidance 2020/21

Update to the GP Contract agreement (EHCH DES)

NHS Long Term Plan


NHS Operational and Planning Guidance 2020/21

York Health and Wellbeing Strategy/ JSNA


Development Population Health Management approaches, in preparation for Anticipatory Care GP Contract DES in 2021/22

Mental Health

·         Suicide rates higher than peers

·         Over half of homeless have MH problem

·         Higher proportion of people admitted with self-harm than peers

York Health and Wellbeing Strategy/ JSNA


Subsequently, developing a multi-agency approach to Covid-19 Preparedness and Resilience was added as a priority.



6.    Progress to Date


The impact of the Covid-19 pandemic has led to some slowing of progress, particularly during March – June as organisations and professionals directed their energy to tackling the first wave of the pandemic. It has since been possible to refocus, and good progress is now being made both in developing specific projects/programmes and developing more effective ways of working with existing programmes led by member organisations.


Priority area

Progress since March and next steps


Closer working relationships have been developed between City of York Council and partner organisations to enhance the effectiveness of existing health prevention programmes. This will be achieved by assessing the impact of specific interventions and ensuring that there is a clear pathway for people to get help and support e.g. for patients identified in primary care who would benefit from smoking cessation or weight management.    

Ageing Well, frailty and multi morbidity

We have used the national “RightCare” toolkit to assess where we are as a health and care system in supporting people to age well and who have identified frailty and have identified opportunities/priorities for the next six months.

Mental Health

We are working to support the Mental Health Partnership to implement Right-Care Right-Place in York and have recently agreed plans to integrate mental health workers into primary care teams.

Covid Preparedness and Resilience

In wave 1 the Covid Hub was developed, which supported symptomatic people whose were at risk of deterioration, promptly referring people whose condition worsened to clinical services - this will continue. We are now working with City of York Health Trainers to develop improved, targeted prevention so that people who have had Covid are supported to make any necessary changes to improve their health and manage their condition.


7.    Future work and further development of York Health and Care Collaborative


One of the most significant areas of progress has been the improved working relationships, particularly through improved engagement with the Voluntary Sector, who play an invaluable role in supporting people and communities.


Partners have shown significant commitment to joint working, despite the pressures that individuals and organisations were under in the early stage of the pandemic; YHCC aims to consolidate progress to date and further develop capability as an effective multi-agency group.