Report of York Health and Care Collaborative; Update July 2022

 

1.    Introduction

 

This report provides update on the work of the York Health and Care Collaborative (YHCC); briefly outlining the scope of each priority workstream.

 

2.    Progress on Priorities;

 

2.1  Prevention

 

The responsibility for leading health promotion and prevention activities across the city is with City of York. YHCC provides a forum to share population health intelligence across a wide ranging provider and commissioning partners including York CVS, and identify where a collaborative approach can increase the impact and effectiveness of interventions.

 

a)    Smoking; prevalence in York is below the regional and national average. However, smoking rates in those with an SMI have increased by 1% in the last year. Through speaking to people with lived experience it is clear that it is difficult to access smoking cessation as there is a perception that people are not trained to manage SMI. CYC are looking to find a provider to educate health trainers in managing SMI.

 

Priory Medical Group started a pilot working with a Health Trainer in primary care to offer follow up interventions after LD and SMI health checks. The success of this was discussed in YHCC and as a result, all of the Primary Care Networks across York have agreed to fund CYC health trainers in primary care.

 

b)    Substance misuse; drugs and alcohol; an update was provided to YHCC on alcohol misuse, an area where overall York performs poorly on most indicators. The community alcohol liaison officers have been running the Changing Habits programme since November 2021 and a number of people have been referred into the service.

 

York has commissioned a service through York Mind to work with individuals that have a dual diagnosis, one of the most vulnerable cohorts of patients, and TEWV are looking at recruiting multiple Emotional and Complex Needs Specialists to work with people that have chaotic lives and complex health needs. YHCC will discuss where it would be best for these roles to be based to have the greatest impact.

 

YHCC are also looking to run a future session about the impacts of drugs and alcohol on children and young people.

 

c)    Weight management, obesity and diabetes; The Healthy Weight Steering Group continues to meet and deliver work on the wider determinants of healthy weight and weight management pathways. An update from the group was provided to YHCC in June 2022. Work is underway to bring partners together to look at treatment pathways for adults and children in Tier 2. Slimming World, GLL and HENRY will continue to be commissioned to deliver services in York.

 

At the June meeting, it was highlighted by a representative from Primary Care that the data for Tier 3 services in York needs to be updated, this will be actioned as a result of the meeting.

 

2.2  Ageing Well, Frailty and Multimorbidity

 

a)    Ageing Well and Frailty

 

The YHCC Frailty Steering Group continues to meet regularly, the aim of the group is to understand how to code frailty and ensure that the coding is readily accessible to all health care professionals supporting frail people. The group has achieved the following:

 

·         Secured funding for all General Practice staff to complete training on Rockwood Frailty Scoring. All practices received a letter in May detailing how the funding can be claimed and some options for delivering the training.

·         Increasing the number of people consented to the Enhanced Summary Care Record (ESCR) so that Rockwood scores can be seen by all health providers. The group are looking to trigger a letter to a patient as soon as they are assigned a Rockwood score to ask them to consent to ESCR.

·         Three workshops are being scheduled to run from September to look at the services that are available for mild, moderate, and severe frailty. Partners from across York's health, care and voluntary services will be invited to attend the workshops.

·         Secured funding for Ardens for this financial year to ensure a consistent approach to identifying, coding, and reporting frailty in General Practice.

 

2.3  Mental Health

 

The responsibility for leading mental health transformation is with the Mental Health Partnership. YHCC supports two main aspects of this work; the aim to achieve better integration of mental health into the broader provision of community and primary care services and addressing the need to improve the physical health of people with severe mental health illness (SMI).

An update was provided by TEWV to YHCC in April 2022. TEWV are working with the Innovation Unit to look at the implementation of hub sites across the City of York. The purpose of the programme is to establish a whole community approach to delivering mental health services where people can receive support wherever they present in the system.

The ICS Digital Lead will be looking at how to introduce a single system that will allow information recorded by the hubs to be accessible in primary care.

Deprivation Workshop – In May, YHCC ran a workshop that looked at the impact of deprivation on access to services. Attendees were asked to consider 'How do people from a deprived background access a particular service, or receive care in a way that is different from the wider population?'

Minutes of the workshop:

As a result of the workshop, YHCC would like to understand from the Health and Wellbeing Board, where it thinks the gaps are in supporting deprived communities in York, to aid the group in future discussions about how YHCC can assist closing these gaps by working together.

 

Covid Recovery Hub – In the June meeting, the group agreed that the Covid Recovery Hub would become a steering group that reports into YHCC. The Covid hub continues to offer welfare calls to those who are at the most risk when they test positive for Covid-19, helps patients in the Long Covid Pathway, and supports the Waiting Well programme by contacting individuals on P4 (long) hospital waiting lists to offer interventions to ensure that they are ready for surgery when they are called. Patients are risk stratified based on a combination of health and social factors to make sure those that the most vulnerable are contacted first. Contacts are then made through care coordinators, social prescribers and health trainers to deliver a range of support.

Since the beginning of the pandemic, the Covid Recovery hub has been a multi-agency collaboration between Primary Care Networks, Nimbuscare, York CVS, CYC and VoY CCG. The collaboration between organisations has ensured a rapid response to the emerging needs of the population of York arising from the pandemic. As the relationships continue to thrive, new opportunities for working together will emerge and align with the priorities of YHCC.

 

3.    Future work and further development of York Health and Care Collaborative in 2022/2023

 

3.1  Diabetes Design Group

 

A design group of GPs with an interest in Diabetes, a specialist diabetic nurse, public health, and NHS commissioners is being established in York to clinically review diabetes services commissioned in primary care, with a view to a future service delivering improved outcomes for York residents diagnosed with diabetes. Like Frailty, the group will report as a steering group to YHCC to ensure opportunities for multi-agency collaboration and an integrated approach are maximised.

 

3.2  Priority Setting

 

Priorities for the group set in 2021/22 will continue into 2022/2023. The group awaits confirmation of any new priorities identified by the ICB and Health and Wellbeing Board from 1st July 2022.