1. Local Overview Chris Badger Operations Director, Older People
Hertfordshire County Council
Alison – thank you very much William for giving us the national picture.
Now we’re going to hear from Chris Badger.
Chris is practically the living embodiment of integrated working. Although he now works for Hertfordshire County Council as Operations Director for Older People, he has previously worked in health commissioning at East and North Hertfordshire CCG and for the NHS community provider organisation, Hertfordshire Community Trust. Chris was in fact on the original Hertfordshire team that successfully pitched for NHS England funding for our Vanguard project in the first place.
Thanks Chris.

2. Background – East and North Hertfordshire
“By 2030 the number of older people with care needs is predicted to rise by 61%”
“2,000 extra carers needed year on year to meet increase in demand”
Rising pressure on care homes:
Unplanned use of health services (e.g. GP, 999)
Delayed Transfers of Care
Staff pressures
Poorer resident outcomes
In 2014, East and North Hertfordshire CCG, Hertfordshire County Council and the representative organisation the Hertfordshire Care Providers Association, successfully secured national funding for our care home improvement ‘Vanguard’ programme.
We pitched to take part in the project because we had a good track-record of partnership working in the county.
We felt very strongly that by working together, we could deliver real improvements to the health and care of our population and build much-needed capacity in both our health and care-home sectors.  The pressures we were, and still are facing, mean that we have to find innovative ways of working, in order to continue to support the population.

3. Care homes in East and North Hertfordshire
This is the picture – in the East and North Hertfordshire CCG area – an area with a population of around 560,000 residents.
The health and wellbeing of our residents is generally better than the national average, although there are pockets of deprivation.
Our proximity to London and the area’s popularity mean that house prices and the cost of living is high – which can make recruitment difficult across the board – but particularly to less-well paid posts, such as care home staff.

4. The issues we face 23hrs £2,626 Disproportionate number of
999 calls from
the over-65
age group
Patients in care homes are more likely to be taken
to A&E than those living at home
Multiple hospital admissions
of less than
one day
£2,626
Average cost of a hospital stay for a patient who has fallen
23hrs
Care home patients on average take seven prescribed medicines
Nationally, on
any given day
70% of patients
experience at
least one
medication error
In common with many other areas around the country, our care home population faces a range of challenges:
Patients in care homes much more likely to be taken to A&E than those living at home
Patients in care homes are often taken to hospital and sent back the same day – which is disruptive and disorientating for them and their carers
Because of the complexity of their health needs, care home patients on average have 7 prescribed medicines – and medication errors are more common in care home residents than in the general population.
Pharmacist visits to care homes can reduce
reported errors
(Barber ND et al 2009)

5. Our vision “
To deliver an enhanced model of health and social care to support frail elderly patients, and those with multiple complex long term conditions in the community in a planned, proactive and preventative way ”
When Herts County Council, East and North Hertfordshire CCG and Hertfordshire Care Providers Association launched our partnership, we recognised that its only by working together that we can:
coordinate health and care services around the needs of individuals
work proactively to address health and social care issues within available resources
help people to live healthier lives for longer.

6. Through our project we have seen:
Fewer
More
999 calls
A&E attendances
Emergency admissions to hospital
Short stays in hospital
Calls to the out of hours GP service from care homes
‘Delayed transfers of care’
Medication errors and problematic polypharmacy
People living healthier lives for longer in care homes
Calls to NHS 111
Staff, residents and families reporting feeling satisfied with care
Care home staff choosing to stay longer in their jobs
People dying in their preferred location
It has been a difficult journey, and in today’s workshops you will hear about the bumps on the road that have – and still do – make progress difficult, and sometimes painfully slow.
Despite the bureaucratic setbacks, we have seen real improvements to the quality of care that we can deliver to some of our area’s most vulnerable residents.

7. What does the project mean for patients?
When Mary moved to her care home a year ago,
she had type 2 diabetes as well as breathing
difficulties.
Training means care home staff feel more confident, helping Mary manage her diabetes through nutrition - with input from a dietician.
Long term condition training covers respiratory problems.
Medications reviewed by pharmacist to optimise and reduce polypharmacy.
During her stay, Mary became increasingly confused. She became more dependent on staff who were not always informed or confident about caring for her long-term conditions.
(NOTE CHRIS – THIS SLIDE HAS TRANSITIONS – THE BULLET POINTS COME IN IN STAGES)
Your going to hear a lot of facts and figures today, which are important – because it is important that what we do is evidence-based and evaluated.
But what’s even more important is the qualitative effect on the lives of care home residents. We have gathered patient stories throughout the life of the project, which you can see on the Vanguard website. But to bring together the different strands of our improvement work, we’ve put together this composite case study:
(TALK THROUGH THE BULLET POINTS AS THEY FLY IN – IMPACT OF VANGUARD INITIATIVES IS SHOWN IN ITALICS)
Confusion recognised by staff with dementia awareness training and staff generally are more confident about looking after Mary as a whole person.

8. What does the project mean for patients?
Mary’s frustration at losing responsibility for her own care led to depression and, without a comprehensive care plan in place, there was little improvement in her weight and mobility.
Input from CPN nurse through MDT and Mary encouraged to join exercise and social/craft sessions.
When Mary experienced complications from her breathing problems, care home staff were unsure what to do and called an ambulance to take her to hospital, which Mary found distressing and disorientating.
Care planning becomes the joint responsibility of Mary, her family, MDT and carers in her care home. Breathing complications prompt care home staff to call frailty team. Rapid Response team carries out assessment on Mary, and supports staff to care for her in her care home bed.
(CONTINUE TO TALK THROUGH BULLET POINTS AS THEY FLY IN)
HOSPITAL ADMISSION AVERTED

9. NHS.net email and assistive technology Early intervention vehicle
Confident Staff
Upskilling staff to feel more confident about supporting residents’ health & wellbeing
Multidisciplinary Teams
Support & advice from pharmacists, dieticians, geriatricians, mental health professional, doctors, therapists & nurses
Rapid Response
A range of services including a frailty vehicle delivering expert care, supported by teams of healthcare professionals, doctors and nurses
Effective Technology
GP access to patient information when they visit them in their care homes and data analysis
Aligned GP contract
HomeFirst
Impartial assessor
NHS.net and assistive technology
Early intervention vehicle
Care home pharmacist
Red bag
Frailty service
Complex care training
End of life training
Improving patient outcomes, like in the example we’ve just seen, is a complex business, and there are many strands to our care home improvement work.
In our workshops today, we can only cover a few elements of the programme – those highlighted here in bright blue - but here is a snap-shot overview of the work we have been in east and north Hertfordshire - from the introduction of aligned GPs for each care home to our frailty service, improved end of life training and care and recruitment support.
Targeted support
Recruitment toolkit

10. Workshops Improving hospital discharge Technology in care homes
Impartial assessor
Red bag scheme
Technology in care homes
NHS.net
Multi-disciplinary teams
Medicines optimisation
Early intervention vehicle
Workforce development
Complex care
These are the workshops which you’ll be taking part in today.
If you can’t remember which one you have signed up to – the coloured stickers on your name badge should remind you!
It’s not possible for everyone to go to every workshop – so your delegate pack has fact sheets on all the topics we will cover today.
All of the resources used today will be available for delegates to download from our website from next Friday, 10 November
But to whet your appetite – here are a few highlights from the day’s sessions …

11. Workshop – Improving hospital discharge
The issue
Care homes insisted on their staff visiting patients in hospital, before deciding whether to accept them
This led to discharge delays and impacted on staffing in care homes
Key facts
Since introducing the impartial assessor in August 2016:
459 assessments completed
358 patients discharged
624 bed days saved
bed-day saving of £327,600

12. Workshop – Technology in care homes
The issue
When patients are discharged from hospital, care homes receive information about their health by fax, in the post, or in person. Sometimes key information is not received at all.
Key facts
the NHS.net secure system is being introduced into care homes
care home staff are being trained on information governance, so patient information is managed securely
this enables a secure audit trail of patient data

13. Workshop – Multi-disciplinary teams
The issue
Each Hertfordshire resident takes around 7 prescribed medicines a day. Around half do not take their medicines as prescribed. The cumulative effect of multiple medications can cause falls and other issues Key facts
Since 2015, care home pharmacists:
have reviewed 1,426 patients and 13,786 medicines
stopped 2,238 unnecessary meds
saved £354,498 in drug costs

14. Workshops – Workforce development
The issue
Patients in care homes are living with increasingly complex conditions. A skills and confidence gap meant that care home staff often called an ambulance as the first response when a resident’s health deteriorated.
Key facts
213 ‘complex care’ champions have been trained
45% reduction in hospital admissions and A&E attendances
Pressure ulcers more than halved