What is the challenge your project is going to address and how does it connect to the theme of 'How can we improve across system boundaries?​

Norfolk has a growing, ageing population, with significant areas of deprivation.

Integrated working is not always easy to implement and often there is a culture of fear or uncertainty amongst our workforce which prevents truly integrated behaviours and practices embedding.

Forging improved relationships across organisations such as community health, General Practice, social care, housing providers and VCSE is imperative. People are increasingly accessing multiple silo organisations at a time of crises or need in their lives. We aim to reduce the need for people telling their story more than once, have clarity on support  through development of personalised action plans – outcomes over processes.

We will build a shared purpose, explore trust and cultural change needed.

Supported by our local Place Board, we have established a development group based around two different GP practice population, building a model to be used as a blue print and guide for scaling up.

What does your project aim to achieve?

·       Reduce the need for the person to tell their story more than once, streamline access into an integrated care team and reduce the need to navigate multiple silo organisations.

·       Increase the coordination of joined up care and support planning across multiple organisations.

·       Improved oversight and engagement from the person and their carer in their personalised plans

·       Increased confidence in workforce in delivering improved MDMs and ensure that improve proactive case finding particularly in the CORE20 areas is a key part of the delivery.

·       Seek feedback from people and colleagues to inform new ways of working, through engagement activities.

·       Identify workforce development needs and secure training to meet these.

·       Gather data and complete analysis of improvements made.

·       Build a shared vision across multiple organisations and explore the issue of fear and cultural change, implementing support and changes to increase trust across organisations.

·       Ensure learning is cascaded through routes available to others.

How will the project be delivered?

Integrated Health and Communities programme is established offering strategic direction.

Operational leaders provide a forum developing next steps and leading on change.

Improving MDMs; use of digital systems,  new templates and processes for shared care planning and risk management, enhanced focus on proactive case finding including a better understanding of the population need and areas of deprivation.
Increased confidence and culture change; engagement with collective workforce to understand emotion behind change, activities including Schwartz Rounds, ‘team’ discussions, staff training, tackling the issues preventing progress i.e. fear and uncertainty.
Resident experience – care closest to home as possible, we need to know the local community and be known to them.  Engagement events with local people, particular focus on people not currently accessing health care regularly but who are at risk of poorer health outcomes.
Establish a shared vision acknowledging teams will create the structures and relationships that ensure ongoing transformation and innovation.

How is your project going to share learning?

The learning from the work will be taken into Place Board and Health and Wellbeing Partnerships and support the development of a model which can be used as a blueprint and guide for scaling up to other areas.

Working with system partners in a  series of workshops to develop next phase of integrated teams. Build momentum to create a culture of continuous improvement.

The learning will be taken into other areas of Norwich and in Norfolk for rolling out to other places, and cascaded through the development group and the stakeholders in it.

The work will inform the Quality improvement agenda for NCHC and across Norfolk & Waveney ICS wide Innovation Network.

Link with colleagues and contact across the country who are also developing integrated  neighbourhood teams and share within the Q Community.