- Somerset County Council and its local clinical commissioning group (CCG) are working together, using local projects to influence a system change towards prevention, early intervention and joined-up working.
- Health Education England has played an important role as a funding partner.
- The initial focus has been on developing a series of commissioning academies, which have become an important part of the delivery of Somerset’s ‘Fit for my Future’ wellbeing strategy and its sustainability and transformation partnership (STP).
The Somerset context
Somerset has coterminous county and CCG boundaries. The county and its partners have been looking to create a more integrated ‘joint commissioning’ approach to the delivery of health and social care, with more emphasis on prevention, early help and re-ablement. As a rural county, isolation, poor social mobility, an ageing population and difficulties in recruiting carers create a strong need to move towards an approach that mobilises local assets in the community.
Results from a baseline survey conducted before day one of each of the first two Somerset Academies validated the hypothesis that, as partners, we did not have the right building blocks in place (relationships, mutual understanding, creativity, an outcome focus) to enable us to work effectively across Somerset’s health and care system.
The Commissioning Academy model
The national Commissioning Academy is run at venues across the UK. The programme uses practical, peer-led learning involving master classes, workshops, guest speakers, site visits and peer challenge, with a focus on implementation. Over a five-day period, it covers key commissioning issues such as:
- commissioning for outcomes;
- whole-systems thinking, bringing all facets of public services together to deal with issues;
- co-producing with communities new ways of supporting people and using local assets better;
- behavioural insights;
- market engagement and development;
- alternative funding models, such as social impact bonds; and
- joint commissioning across organisational boundaries
Each participant is a part of a mixed sector cohort of up to 30 participants. The cohorts are designed to provide as much diversity as possible to maximise learning from experiences across a range of public service organisations, including central and local government, justice sector and health bodies, and ‘place-based’ groups (where organisations are working together in one area).
The Somerset Academies programme
The Somerset Academies programme tailors the national approach for Somerset.
- It focuses on the challenges in the health and social care sector.
- It involves a five-day programme run over a period of five months.
- ‘Challenge projects’ build momentum through action research and creating a 100-day action plan to make real change happen.
The aim is for partners to work together as place shapers and system leaders, building a mutually supportive ‘team’ ethos across Somerset by developing stronger relationships, shared understanding and collaborative behaviours and adopting a strengths/asset-based approach.
The programme supports people to live independent and positive lives by:
- promoting wellbeing and independent living;
- providing person-centred support;
- fostering partnership working and collaboration;
- encouraging strength-based conversations;
- exploring sustainable, community-based solutions; and
- focusing on outcomes
Our story so far – evolving the Academy for local impact
Two cohorts have engaged in the programme so far, a third is in progress and a fourth is being planned.
The first cohort closely followed the Commissioning Academy format and was funded by Somerset County Council. Locally, the emphasis was on commissioning for outcomes, co-production and leading across the system. Participants came from the county, local district councils, the CCG, police, and the voluntary sector (Community Foundation).
We decided to organise the programme around group projects. Leaders from across the system suggested and sponsored participants, who were then allocated to the projects. The projects were broad by definition and part of the academy approach was to help project groups, through facilitation, to develop a focus. ‘System leaders’ attended on days two and five to work with the teams in order to help guide projects.
The projects were designed to deliver change and promote a shift in commissioning – initiatives such as Community Connects (local community support) and Home First (enabling discharge from hospital) started following the programme and are attributed to it.
One project explored how to create a broader community response in Cheddar and Axbridge to a range of health and wellbeing issues, using asset-based community development approaches, and established a ‘Seattle-style’ community fund to support local wellbeing initiatives.
A data sharing protocol between the NHS, local authorities and emergency services arose directly as a result of a project looking at how better to support frequent attenders at A&E with multiple needs, but found that sharing data to analyse the issue was an obstacle.
A housing (HMO) project in part of Bridgwater used asset-based thinking and co-production with local groups to integrate single tenants better into the local community. The project succeeded in bringing voluntary groups operating in the area together to help enhance the local environment in co-production with the community and the project has also influenced the broader Somerset strategic housing framework.
The second cohort was set up in a very similar way to the first. However, funding switched to Health Education England. The cohort saw an increased focus on asset mobilisation and development. The cohort also started to involve the Somerset NHS Trusts’ quality improvement (QI) faculty and methods.
A 100-day follow-up workshop in October 2018 indicated that projects were continuing in a range of areas:
- tackling the high number of home-educated children in the county and how to enable them to be employable;
- identifying early signs of self-harming in children – this work has fed into commissioning activity aimed at prevention, in support of Somerset’s ‘Fit for my Future’ wellbeing strategy;
- exploring (via a data group) how data can be used intelligently to improve targeting of resources;
- commissioning a role to support young people’s transport in West Somerset, which has the lowest social mobility score in England;
- specifying a website for young carers; and
- starting a falls prevention education campaign, aimed at 50 to 65-year-olds supporting their parents, thereby also making this younger generation ‘falls aware’ as they themselves age
This cohort is still in progress (as at March 2019) and is funded by Health Education England. The cohort is more health-focused in terms of participants and has integrated the QI faculty and methods more closely into its activities. Attendance was affected by the winter pressures on the NHS, but the group has maintained around 20 to 25 members.
The projects are more specific and as a result have thrown up systemic issues which may present potential barriers to progress. Therefore, we have been holding calls with project teams between academy days, looking more at root causes in some cases and prototyping in others.
Once again, there is a range of projects.
- Young people who go ‘missing’ often have complex needs and poor and expensive outcomes. How can earlier help and integrated working improve outcomes?
- One group is working with businesses in a retail outlet village with high shopper footfall to create a dementia-friendly environment, building on existing initiatives.
- Another group is prototyping/testing an ‘advanced care (end-of-life) planning protocol’ with micro-providers and families in Minehead.
- Yet another is seeking to understand and respond to paracetamol poisoning (self-harming) through prevention and behavioural strategies.
- Finally, one group is exploring the pathway associated with ‘medically unexplained symptoms’.
A fourth cohort was agreed in February 2019 with Health Education England funding.
The model is moving towards collaborative commissioning, continuous improvement and the direct delivery of projects, sponsored through the STP delivery boards. The academy is being redesigned to do this, with greater joint ownership and an approach focused more explicitly on system change and integrated health and social care. The Public Service Transformation Academy will lead a group of County Council, NHS and Somerset Quality Improvement Faculty (SQIF) representatives to carry out the redesign.
Projects are therefore being given more support in how to leverage the national academy tools and QI methodology brought into the development days. System leadership to deliver a more integrated care system will also be a focus.
Overview of the programme flow
Key partners include:
- Somerset County Council;
- Somerset CCG; and
- Health Education England through the STP local area workforce board (LAWB)
Latterly, they have been joined by:
- The NHS QI faculty; and
- South West Academic Health Science Network
What’s been the impact of our work?
Cohort 1 demonstrated buy-in across the system, with take-up (aiming for a minimum of 25 participants) exceeding expectations. Forty people participated from across Somerset County Council (including children’s and adults’ services, economic and community infrastructure, and public health), the CCG, primary care, the police, district councils, the Department for Work and Pensions and Somerset Partnership NHS Foundation Trust.
The feedback was excellent, with 100 per cent of participants reporting on day five that:
- they had made useful connections via the academy;
- they had learnt from other academy participants; and
- the academy had been relevant or highly relevant to their individual learning needs and had been a good or excellent use of their time
Meanwhile, cohorts 1 and 2 demonstrated the following impacts, as set out by the LAWB:
|Developing stronger relationships and a shared approach||System leaders commented on the commitment amongst the participants to improve the way we deliver services across the system and on the shared language which had developed during the five days.|
|Seeing a step-change in collaborative behaviours and system leadership across the system||The range and calibre of representatives from across Somerset’s health and care system is viewed by the academy delivery partner as an exemplar.|
|Applying effective outcomes-focused, place-based commissioning which builds on strengths/assets and co-production||Three of the challenge projects have used an asset-based commissioning approach with some impressive results. These also provider great examples of co-production with local communities.|
|Taking forward actions and plans produced by challenge teams that lead to embedded and sustainable change and outcomes||One project has rallied the whole system in finding a solution to data sharing across the health and social care system.
Another has established a fund for community activity in a locality of Somerset and has paved the way for the Stronger Communities workstream.
|Shaping the journey towards a more integrated health and social care system||Taking the learning from cohort 1, subsequent cohorts have been shaped with health and the programme adjusted to encompass the quality improvement (QI) methodology, which is largely practiced in acute health settings. This will help us in our objective to talk the same language across partners.|
The key elements of our success
Many factors have contributed to our success.
- Identifying the specific challenges before day one of the academy encouraged greater system-wide buy-in.
- We have involved people from across the system in identifying these challenges and pinpointed the participants who will benefit most and have most to contribute to each specific challenge.
- Previous participants and senior system leaders are used to identify specific challenges and agree participants. We learned and evolved to bring in the STP delivery boards into this process.
- We benefited from the collective insights of people across the system who understand what type, scale and scope of challenge the academies can help address.
- Working closely with the NHS QI faculty in Somerset has opened up involvement of the NHS Trusts.
Day five evaluation cohort 1: will the programme lead to action?
And if we were starting again…
If we were starting again, we would take even greater account of:
- the challenges of working effectively with participants who are affected by the massive pressure the system is under as a result of high demand for services combined with the need to implement major change programmes to achieve (austerity) savings;
- given time is at a premium, the need to set up the programme to ensure full buy-in from managers and participants – one way being to seek greater clarity at the outset from system leaders about the project areas that interested them and another being to build stronger emphasis on the team ownership of projects before day one;
- the importance of group leadership and drive – distributed leadership is fine, but the groups needed resources to push the work forward between the academy day meetings; and
- the value of meeting ‘on the day’ but the challenges of organising the sessions
Our key contacts
Vikki Hearn, Strategic Commissioning Development Manager, Somerset County Council and member of Somerset Quality Improvement Faculty firstname.lastname@example.org
Jo Howarth, Deputy Director of Nursing, Yeovil District Hospital and member of Somerset Quality Improvement Faculty email@example.com
Andrew Fisk, Learning and Development Consultant, Somerset County Council AFisk@somerset.gov.uk