Equally Well strategy

Supporting everyone to live healthier and fulfilling lives and maintaining independence for longer

Throughout the pandemic there were impressive collaborations between organisations that served and supported all our communities in a joined up way. The drive to integrate health and social care services is greater than ever, with improved experience for residents and more community-based support being delivered closer to home being our local objective.

There is no single definition of integrated care and services can be joined up in different ways, for example between primary and secondary care, physical and mental health care and health and social care. The key aim is to reduce local health inequalities by improving access and unnecessary variations and fragmentation in care

What does the evidence say?

The NHS Long Term Plan indicates that integrated systems for health and social care provide stronger foundations for the NHS to work with local government and voluntary sector partners on the broader agendas of prevention and health inequalities, ensuring plans include co-ordinated action on the wider determinants of health including employment and poverty

Joined up approaches are required targeting services to the needs of individuals, families and communities most likely to experience health inequalities using available data, for example demographic, equality and diversity and wider determinants data.

Integrated care is most appropriate for those living with chronic illnesses or long-term conditions, frail older people, those with complex needs and their carers, or those requiring urgent care. It is most effective when it is population-based and considers the holistic needs of people.

Examples of our current approaches

• The North Tyneside Transformation Board (Future Care) was set up to consider how health and social care services can be most effectively integrated where required
• Locally, there will soon be an integrated care system (ICS) in place. This will be comprised of an ICS Health and Care Partnership, bringing together the NHS, council, and key stakeholders to support integration
• Four Primary Care Networks have been established in North Tyneside (North West, Wallsend, North Shields, Whitley Bay) and have collaborated to deliver a range of objectives around extended hours access, access to clinical pharmacy and development of social prescribing initiatives
• Living Well North Tyneside has also been jointly established by partners, to make health and wellbeing information easier to find and access online
• Social prescribing and care navigators are available to help people through primary care networks and access appropriate levels of support
• CARE point is an award-winning multidisciplinary team partnership between the NHS and Age UK North Tyneside to address frailty, health and wellbeing in older people and promote independence
• The North Tyneside Ageing Well Strategy aims to be integrated, person-centred, safe and inclusive
• Partnership work continues to support carers and improve carers’ experience, ensuring that they are safeguarded and their welfare is promoted
• Partners across North Tyneside are working together to begin redesigning the local community mental health model
• Adult Social Care are working to increase the use of technology within the homes of residents who have social care needs; aiming to use smart technology and devices to improve resident access online
• Local partners across statutory health and care services and the local voluntary and community sector have established a joint steering group to combine efforts, ideas and solutions to tackle the barriers that exist locally to integration
• Northumbria Healthcare Trust have established a Health Inequalities Board, working with key partners to support an integrated approach to tackling inequalities in access, service use, experience and outcomes, to address inequalities in the workforce and to influence the wider determinants of health

Key local challenges and areas for action

• All plans need to incorporate system, scale and sustainability – and specific actions from all partners to address the wider determinants with a specific focus on improving the health of people with the poorest health outcomes fastest
• Financial pressures can be a barrier to shared planning and pooling resources
• Integrated IT systems are needed to support and aid integration
• Identifying and closing the gaps in care which have the most impact on health inequalities
• Managing demand in the acute sector
• Ensuring it is easy for local residents to ‘navigate the system’
• Developing capacity with Primary Care Networks who can play a pivotal role with local authority and community partners in improving population health and reducing inequalities

Innovation and integration – Backworth Ageing Well Village

Northumberland Estates, working with leading charity Age UK North Tyneside and a range of health and social care local providers, are working together to create a state-of-the-art residential development for people in later life.

The aim is to design and build a multi-generational living and wellbeing complex capable of offering a wide range of services to support people in later life and to help them make more of life too, by creating a real interactive community.

An integrated health and social care hub where a range of integrated services work together to promote faster recovery from illness, prevent unnecessary hospital admission and premature admission to long-term residential care, and maximise independent living.

Sustainable development will be key using sustainable and locally sourced materials, incorporating green roofs, with a green ethos of living with nature to further health and wellbeing throughout, which encourages residents to contribute to and conserve their outdoor environment.