The WRaPT team guided local clinicians and leaders through the workforce redesign process to help them determine the future state of the workforce for the Bay ICC. This involved three key elements:

Data Collection

The team collated and analysed current activity and population demographic data to determine a series of “proxies” (as per the Population Centric framework) which represented the major burden of care for current acute and community services from the following:

• A&E attendances
• Admissions to Acute Hospital (UHMB)
• Primary Care data
• Community Nursing and Therapies data

Key stakeholder interviews then took place to ensure that the assumptions taken from the data lined up with the reality, as the clinicians see it on a day to day basis.

Workshop design

The team presented a plan for a workshop to the key stakeholders of the programme to ensure the aims of the Bay ICC could be met; to deliver their goals of reducing unnecessary attendances to A&E, unnecessary admissions, length of stay and the overall health of the population they serve.

Workshop delivery

The workshop took place in December 16 and brought together stakeholders from across the Health and Social Care sectors as well as the third sector including Social Care, Community, Primary and Mental Health as well as Police, Nursing & Residential Homes, Community Pharmacy, St John’s Hospice and West End Impact.

The session built on the Population Centric approach, introduced in a previous meeting of the stakeholders through the utilisation of “proxies”. The WRaPT Team created “proxies” based on patient cohorts identified in the Bay ICC population, these were used to engage with the group to answer three key questions:

• What are we currently doing well and how can this be improved?
• How can patients be managed to ensure they are kept in the community rather than attending a hospital for treatment?
• What skills and competencies would be needed to carry out the new ways of working?

The outputs from the session were both numerous and wide ranging and therefore have been summarised into ten key themes:

• Emphasis on early diagnosis / prevention / self-care
• Educating patients – 1) on their condition 2) accessing the right service
• Identify and promote existing services within our own staff and the public
• Increase / promote technology options such as Telehealth, Remote Monitoring, Apps
• Holistic assessments between health and social care
• Develop a single point of access
• Develop understanding of Care Coordinator role
• Increase the utilisation of Pharmacy
• Investigate status of other BCT workstreams that may have an impact on the ICC i.e. Children’s services, Respiratory, Cardiology etc
• Utilisation of community resources including the Third and Voluntary sectors

The team presented the outputs back to the key stakeholders and asked them to review and agree priorities for the new integrated care team.

The team also outlined the next steps that the WRaPT team will lead, these are as follows:

• Analysis of patient and population data for Bay ICC
• Identify Patient Cohort for an Integrated Care Team
• Use the 10 key themes from Workshop 1 and research best practice from other areas linked to each of these themes
• Align the findings from the data analysis and research to Bay ICC
• Validate assumptions with key stakeholders
• Collate workforce data for Bay ICC integrated team
• Map current workforce and activity
• Produce a model in WRaPT

The team also worked with the key stakeholders to finalise the next steps that the WRaPT Team will lead, these are as follows:

• Analysis of patient and population data for Bay ICC
• Identify Patient Cohort for an Integrated Care Team
• Use the 10 key themes from Workshop 1 and research best practice from other areas linked to each of these themes
• Align the findings from the data analysis and research to Bay ICC
• Validate assumptions with key stakeholders
• Collate workforce data for Bay ICC integrated team
• Map current workforce and activity
• Produce a model in WRaPT