Rob Webster: STPs and social prescribing

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Rob Webster, Chief Executive of South West Yorkshire Partnership NHS Foundation Trust and STP lead for West Yorkshire, discusses social prescribing as part of the West Yorkshire sustainability and transformation plan (STP).

This presentation was recorded at our conference, Social prescribing: from rhetoric to reality, on 18 May 2017.

Transcript

Thanks Chris and hello everybody. It’s probably worth starting by saying this is one of the most positive and fantastic and inspiring days I’ve had this year.  And the narrative that we’ve had I think is totally counter isn’t it to the conversation we often have about health and care, but it’s a real and genuine one I think, and one that I often see in my organisation.  And I’m going to talk a bit about STPs, a bit about my Trust and a bit about what we’re doing to deliver a different kind of future for people and one which is a bit more about their lives, and a bit less about our institutions.  Obviously that’s what people are expecting.

So my name is Rob, I am a Trust chief executive. And when you think of an organisation like mine, as a provider of mental health services, learning disability services, community based services, you might think of the buildings that I inhabit which have lots of barbed wire around them often, and have people detained in them, actually my organisation is also a big community provider, most of my services are delivered in communities.  We’ve got a mental health museum which most local school kids come through to learn about the history of mental health in the future.  We’ve got four recovery colleges which look at how you support people to be well through education, and we sponsor and fund creative minds which is a collaborative of leisure, sport and cultural pursuits which facilitates things like Deb’s World.  So I think we’re very much part of the social fabric.  So the mindset people have got about us is we’re an NHS Foundation Trust, the reality is we’re part of the social fabric, and I think that’s really important and very much part of what I hope I brought to the STP.

So the first thing to say just briefly if you don’t know about West Yorkshire and Harrogate, it’s very complicated. So it’s a busy slide, because it’s very complicated, it’s very big, it’s the third biggest in the country.  The health sector alone spends nearly £5 billion pounds a year and has a workforce of about 113,000 people.  And there are huge numbers of organisations in the NHS, local government and elsewhere, never mind care homes, third sector, General Practices and so on.  So what we’ve got is a very significant geography, with a significant number of organisations in it.  And what we have to do is make sure that in trying to think about a sustainable future for the health and care system, there have got to be some things that bring us together.

Now as a group of leaders, the first thing I’d say is the sustainability and the transformation planning process is a plan. So it’s not an organisation, it doesn’t have a headquarters, you can’t go and visit the staff.  It’s a network of people who’ve said we want to make a fundamental difference to the lives of people so that the health and equalities are reduced, the care variations addressed, and the finances are managed in a way that we can afford.  Now what we’ve said to make sure that we can deliver our STP is that we exist for one reason, that’s to improve the outcomes of local people and deliver the five year forward view.  So if you ask anybody that’s what we’re doing it for.  And there are some principles which apply which are relevant.  So the first is that we’re ambitious.  So the kind of buzz you’ve had today isn’t because you want to just get by, it’s because we’re ambitious for the people we support and the staff that we employ.  The second is that this belongs to everybody, it’s not for commissioners or providers or local government or the NHS, it’s everybody together.  The third is that we’ll do the work once, because I think as somebody said earlier we’re very good at complicating simple things.  The fourth is we will have a shared analysis of the issues even if we don’t agree on the action, and the final is that subsidiarity principles apply.  You do the work as closest to the problem as possible.

Now many people think well okay Rob I get that, so that means that we do things in Wakefield, or we do things in Calderdale. I think I said...that’s right, actually we might do things in the practice, or we might do it at the level of the individual.  So if you think about this agenda today, about the level of the individual, if you take subsidiarity to its ultimate end, that’s what we’re talking about.  So as an organisation, as a set of organisations, we’ve got some guiding principles and a shared outcome, because if it’s this complicated, you need something that binds you together.  Now this is really important because STPs have had a bit of a rough ride, and there are secret plans aren’t they to cut hospital beds in the context of A&E closures and this going on.  And one of the things we haven’t really talked about today is how do we get by when this is the narrative?  Because what I think I’ve heard a lot today is, the way that we work with people and communities, is to get to the heart of the matter and the root problem.  So I would say in the system this stuff about waiting, A&E and so on which everybody is really obsessed about, is a symptom of what’s going on in the system.  At its heart it might be the fact that there is a notion of unhappiness behind closed doors in every community which is unseen until it washes up at the front door of A&E.

So as an STP we need to say that you can deliver improvements in these things, but what you’ve got to do is have some ambition, and our ambition is quite straightforward, and quite a simple narrative. So in West Yorkshire and Harrogate what we want to do is get to the point where to be sustainable we have healthy places.  So you have a good start in life, you live well and you end well.  If you’ve got a long term condition you look after yourself because you do anyway, but you’re supported to self care through your peers and through technology.  If you’ve got a few things wrong with you, then there’s joined up services that look after you and support you.  You deal with the things that you want for your life and that you’re part of the team, your carers are part of the team, the NHS is part of the team, third sector is part of the team and care is part of the team.  When you get sick you’ll go to a local hospital, it will be networked with others so that it’s sustainable.  You might have to go further away sometimes to a centre of excellence, but it will save your life.  All of that gets paid for once by the council and the NHS working together and you as a citizen are involved in the design, the delivery and the assessment of that care.  So that’s the vision of ambition for West Yorkshire and Harrogate.  And I bet if you read every single STP, that’s what they all say.  They will take hundreds of pages to say it, but that’s what they all say.

Now that isn’t there’s a crisis in A&E so we have to support hospitals, we have to support hospitals by getting to the root cause of the problem. And if we’re going to do that we have to take a fundamental shift in the way we think about care.  And that shift is to stop seeing people as guests in our organisations, stop writing to people and telling them when to turn up.  If they don’t behave in a certain way they have to go away again and do that in capital letters by letter.  What we’ve got to do is recognise that we’re a guest in people’s lives, and if we think about their mental, physical and social needs, and what assets they’ve got and they’ve got around them, we can redesign care in ways which we’ve talked about all day.  So that’s one of the fundamental shifts we want to get to within the West Yorkshire and Harrogate STP.  If you look at these slides afterwards, there’s loads of hidden slides alongside these which show you the targets that we’ve got, the activity that we’re doing, the evidence base and everything else, but I’m not showing you those at the moment.

Now on that basis, we do start with communities, and as the leader of the STP having authority to tell people what to do, I can convene and connect. And the first thing I’ve done is to say well you’ve got six places, they have a place based plan, that place based plan has existed since 2012.  It has been looking at the joint strategic needs of local people and it has involved everybody through health and wellbeing to think about how you make that better.  So let’s have six plans that address the issues that are in the five year forward view that deliver the kind of vision that we want around future services.  And those are all different, because the communities in those places are different, you know?  If 20% of the population of Dewsbury comes from a banner community, that’s fundamentally different from the population in Leeds, or different bits of Leeds.  South and East Leeds has more in common with Salford than it does with North West Leeds.

So we’ve got six place based plans and the majority of the work in our transformation plan takes place there. So the idea of a hierarchical approach to life with West Yorkshire and Harrogate with me in charge, telling them what to do is redundant.  There is collaborative of local people trying to make things work in local places.  However there are also some things that we have to do at West Yorkshire and Harrogate level, and there’s three tests for those.  So the first is that there’s a critical mass issue.  So cancer services, urgent emergency care and other things, because of their scale, you have to plan them on that population.  The easy way to think about that is if you get run over coming out of your house and you live in Halifax, the extent of your injuries might mean you go to Leeds.  So it’s a West Yorkshire and Harrogate type approach.  The second test for why we might do something at West Yorkshire and Harrogate level is that we want to reduce variation and share best practice.  So if somebody is doing something good, so let’s all do it, and then the third is we don’t quite know how to deliver what we want to do.  And you can see that the sort of things that are in there are Primary Community Services models, standardisation and commissioning and so on.

Now just to alight on one of the themes of the day. We started off with Helen and Michael talking about GPs united around a future for Primary Community Services.  And we’ve got a Primary Community Services work stream at West Yorkshire and Harrogate level that says every place wants to redefine the offer for its population through a joined up model of Primary Community Services which has social, mental and physical health care.  So what do we want to do?  We want to share practice around that to make it go faster.  We want to work out how do you make it work in practice so that we can all do it, recognising that it’s tough, it’s really difficult stuff this.  And this isn’t about being defined by the out of hospital space, it’s about saying we fundamentally need to change care in Primary Community Services to change all care.  And all our work streams are led by chief executives, partners from the voluntary sector and Healthwatch and others.  And what we’re saying on this one is that if you think about people, either the acutely ill patient, the developing person, or the deteriorating patient, currently we provide care in this kind of way.  You deteriorate and you go into hospital, you develop and we think about you in terms of self care and primary care and so on.  What we want to do is just shift all of the care to the left, so we’re fundamentally thinking differently about the way that care is delivered, because the clinicians, the population, tell us that that’s what should happen.

Geriatricians tell us that the significant proportion of people that they support shouldn’t be supported in acute units where you’re warehousing older people who should be at home and independent. Now if we’re going to do that then what we need to do is make sure that we’re accelerating what goes on in communities.  So each of those places that we work has an arrangement like this, and the leaders across the pitch, whether it’s patients, service users, communities or clinicians have said right we should work on four things together.  Shape of the future workforce, the interface between this and the hospital, how community services looks and social models and self care, because they are a fundamental part of this new model of General Practice.  We’re not just talking about having GPs supported to deliver the same thing, we want something fundamentally different and better.  And those work streams, just to alight on one of them, one of them is looking at what’s the interface between primary and self care like then if you take somebody’s life?  And what is it that we’re seeing that really works in the different places where you’re designing those models?

So you can see that as a priority, what we should be doing is looking at lifestyle services, like community pharmacy, people talked about that earlier, social prescribing, patient volunteers and peer support, care navigation, media and digitally enabled platforms. So the idea that the world exists and bends to our will in an era where people can share their own information, set up their own groups, use digital platforms, is one that we just need to harness and change.  So this work is being led by a couple of really great people, so Alison McGregor who is in the audience, and a whole host of other people who are advocates of the work are saying ‘Okay if we’re going to make this work, if we’re going to say we’re fundamentally changing the model of Primary Community Services, then we’ve got to make sure that we’re supporting that right across West Yorkshire and Harrogate because people are trying to do that today’.  And the two big priorities then are, what we have to do is get the place based plans right, and then develop the social models which engage communities so that there’s the right connection between the two.  And I think this is one of the fundamental points.  We can’t create services and then expect people to come, we’ve got to connect things that already exist, we want a better whole, and make the connections work for people.  So these are big priorities across the whole of West Yorkshire and Harrogate, to give us a sustainable health and care system.

Now the other thing that we’re doing is saying that’s fine. So we’ve got this new set of services, these models, but we’ve got to harness and foster the power of communities today.  And there are ways that we can do that with the third sector and with others which make it easier to see what’s going on.  The idea that General Practices for example as community organisations know everything that’s going on with their population, is blatantly untrue, unless somebody is helping them.  I know Hale are here today for example from Bradford, who are helping practices to map all of the community resources that are available locally so you can engage between the two, I know Alex will talk about this as well.  So one of the other fundamental things within the West Yorkshire and Harrogate STP is, we’re saying what’s the deal with the people who will help us think about communities so that we can connect communities together, and we can use those communities to develop a new model of service which is right across health and care and right across the sectors.

Just to give you an example of how that plays out in a place. So six place based plans.  If you took Wakefield which is one of them, it has got an urgent emergency care vanguard, it has got a connecting care vanguard, it has got a care home vanguard.  And again if you look at all the detail behind the slides, there’s lots of evidence on this, I’ll just skip over some of it.  But they’ve got a plan which is owned by everybody which talks about delivering the five year forward view.  They’ve then got a model of care which talks about bringing together a lot of the elements that have been described today.  Because social prescribing on its own won’t solve anything, it has got to be part of a bigger system.  It has got to be about connecting the communities and the assets to the service and the support, and that service and support is bigger than just social prescribing.  So if you look at Wakefield for example, populations based around registered lists within General Practice have access to community anchors and micro commissioning, they have pharmacy and General Practice relieving the stress and pressure of the workforce, they have physiotherapy first to make sure that MSK issues are dealt with which impact upon people’s physical and mental health.  They have care navigation, social prescribing, digital self care and a citizen held record.  We’ve got disruptive prevention, so we go out to schools and we have a schools app challenge where the winners work with Microsoft to get their apps implemented, and the ideas they come up with are just truly fantastic, so kids coming up with a dragon in the attic bullying app which describes behaviours through a game which stops people from bullying for example.

We have a pop up practice to pop up in places where people don’t engage or get care, and within the practice is social prescribing, debt counselling advice and so on. We have primary care champions and we have things open more often, and that’s connected through an information hub and a fusion cell of all the right people in the system to the rest of the system to make sure that people, if they end up getting so sick they have to go to hospital, they’re back into planned care and back into communities as soon as possible.  Now for each of those elements, we’ve been doing evaluation of the impact, and again in the presentation if you want to have a look online later, you can see all the evidence against what happens around micro commissioning, what happens with pharmacy and General Practice and so on, but I don’t have time to go through that.  But for the social prescribing work that we’re doing, similar to what we heard before from Halton, 64% improvement in people’s health and wellbeing for those engaged in health and wellbeing.  The community anchors ensuring that schools, playgrounds, community centres, mosques, the places people go, are a source of advice and guidance and connection that make a difference.  And giving budgets to small organisations to keep people well and develop services where there are none, through micro commissioning, making a fundamental difference.  So again you can see interventions making a difference there with significant impact on people’s lives.

If you wanted to have a look at each of the bits of evidence round all of the interventions and how they add up, they really make a difference. But we don’t just work in communities, we work in care homes and care homes are people’s communities.  So if you looked at the kind of work we are doing with people like Age UK to engage people, developments like Pull Up A Chair, an interview process which is filmed, a video diary process with older people, to talk about their lives, their hopes and their dreams, that allows people to engage differently and for services to understand what they really want in their life, to then engage in community anchors to see what sort of support and care you could connect people to.  If you then look at The Leaf Project which looks at a systematic way of looking at the quality of life and the outcomes for people, if you apply the portrait of a life where people with the dementia have life mapping with the people that are working with them, so that they can have a conversation about their lives and their hopes, not about the weather, and that engages them in the activities that are going on within their daily lives and changes their outcomes, all of this makes a difference.

So if you apply all those things in something like an extra care housing provider, like Wakefield District Housing, magic happens. So before we put all of this into this housing provider, 38% of people left and went into residential care, last year it was zero, nobody left.  Everybody stayed well enough to be independent enough to live their life as full as they could through the interventions that we’re making.  And if you look at the comparisons in care homes for all the interventions we’re putting in, to make sure that people have access to social, mental and physical support, then the impact on the system is significant, 19% reduction in emergency admissions, 12% reduction in A&E attendance and for your ambulance call outs.  So that’s great for the system, it’s even better for the people who aren’t going into residential care.

Don Berwick came along to see this and was very positive about it all, talked about passion, talked about truly extraordinary results, talked about the difference that people were making, talked about the kind of buzz that we’ve had here today. Now as I say I haven’t got the time to go through all the detail, but you can imagine this model in Wakefield, which is being implemented and connected through the Third Sector Council’s primary care, my services, community services, the citizen, is also being developed in Bradford, it’s being developed in Calderdale, it’s being developed in Kirklees, it’s being developed everywhere.  What we’ve got to do is pick up the learning from the last session, you’ve got to do it local, it will be different.  How do you accelerate, how do you make it so mainstream, so important, that you recognise by doing this you will have fantastic outcomes and you also make sure that the system is sustainable?

Where is the evidence? Well there’s plenty of evidence.  If you want to look at the return on investment, let’s look at the individual return on investment that Debs talked about earlier.  It costs less in the art support that she got for two years than it cost her in drug therapy for a single year.  The return on investment for her and her family is astonishing and that is played out right across the board.  And if the five year forward view and the STPs are about reducing health inequalities, if they’re about changing the care variation that exists, and if it’s about the financial reality that we find ourselves, we’ve got to recognise this which I pinched from Alison who sent me a paper about this yesterday.  A big community secret is a lot of this already exists, self care already exists, people look after themselves.  What we’ve got to do is see it, value it, connect and support it, because if we do magic happens, lives are changed, and we could just have a viable and sustainable NHS.  Thanks very much.

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