People, Place and Purpose: Our Living Well Learning History

The lady might have had her feet amputated

if we hadnt got to her. She had clearly been
discharged from hospital too soon and had
been readmitted. Had we not got to her,
she would be somewhere in a home recovering
from amputation Volunteer
20% improvement in mental wellbeing
19 volunteers + 5 co-ordinators
Recruited cohort now at 463

Im at the stage with it now that I need to
see something a little bit more tangible. Now
my head is working a bit fasterIm keen to
see something happen Practitioner
Induction training package produced
Community Line proposal developed
MDT/care co-ordination proposal developed

My concerns are that the project is predicated
as a major saviour of the current crisis GP
Accident & Emergency activity
Emergency hospital admissions
Outpatient first appointments
Minor Injury Unit attendances

Initial results for the first 100 people
1

Authors
Rachel Murray and Tracey Roose, on behalf of the Penwith Pioneer Programme Board,
15
th
October 2014

This is a headline document with key supporting texts embedded. If you would like copies of
any of these documents and you are unable to access them online, please contact
rachelmurray1@nhs.net
2

Our story
This is about people, place and purpose: our focus is on the person - understanding their
aspirations and relationship with their community; our shared purpose is shaping everything
around that. This is the unique selling point of Living Well.

The beginning
In the 2009 and 2010 Age and Ambition events a collaboration led by Age UK Cornwall &
Isles of Scilly, Volunteer Cornwall with support from the Duchy Health Charity, local
authority, health and private sector partners we heard from local people about their future
hopes and aspirations. Over 1,500 people and 40 organisations came together and told us:
Services were not connected
Information is delivered from an organisations, not a persons, perspective
People want to be involved in, not just consulted on, their services
People have skills and experience they want to contribute.

Together we developed a set of principles:
Stop creating new layers support existing groups and connect people together
Communicate whats available and where in a way that people find useful
Encourage local leadership and engagement
Be bold and be brave!

These became the Changing Lives principles that were widely adopted in Cornwall. All of this
was expressed in the Wall of Wishes and Trees of Talent, which were used to start
conversations about changing the way we provide and deliver services.







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The voluntary sector began to test this approach through commissioned services such as
ViVa; Get Well-Stay Well; Steady On and memory cafes. Wrap-around care for people with
long term conditions supported by trained volunteers and paid co-ordinators was tested as a
proof of concept pilot in the Newquay Pathfinder, the success of which led to the Penwith
Pioneer and expansion into East Cornwall.

We have continued to develop the approach using learning from national and international
practice. Studies in Nuka, Alaska and San Diego were instrumental in developing our Triple
Aims, which serve as our evaluation framework for to understand the potential of our Living
Well approach. The aims are to:
Improve quality of life
Improve the experience of care and support
Reduce the cost of care and support.

In Nuka and in San Diego we saw a ground-up co-designed approach that had great results.
We have used their work and our membership of the Institute of Health Improvement to
share experiences with organisations on a similar journey.

As we continue to develop our thinking and search for best practice, we have also seen some
great examples in Denmark and Sweden, where a hospital discharge programme offering
people a supportive visit within hours of discharge showed a marked reduction in
readmissions and an improved quality of life. This approach is being developed as part of the
winter resilience programme. Welcome Home will create a network of trained volunteers
offering a home visit to anyone who might need it, to check that people are able to readjust
when they get home from hospital and that they have all the practical support they need.

Elsewhere we are looking at new models for future care delivery, from accountable care
organisations in the USA to social impact bonds in Peterborough. Our aim is to continually
advance our shared vision to help people to live their lives to the best of their ability.

It starts with a conversation
Our approach is to help people build self-confidence and self-reliance by providing practical
support, navigation and co-ordination. This helps reduce dependency on health and social
care, including hospital admissions. We work in teams with the voluntary sector, district
nurses, GPs, community matrons and social workers to provide wrap-around support
targeted at those most at risk of increased dependency and hospitalisation.

It begins with a conversation between the person and the Age UK co-ordinator, who helps
them to identify their goals and then co-ordinates a management plan. Trained volunteers
then provide continued support to build social networks around the individual, helping
them become better connected to their community, increase their physical and social
activity, which in turn impacts on their health.
Our learning so far
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We have learned that there are key elements of the Living Well approach that are essential
as we extend to other parts of the county. We know that the journey is also important and
that this approach has to be developed ground-up, with local people and with a local flavour;
too often in the past we have transplanted a good idea from one place to another expecting
it to work the same way - it may not. These are the building blocks that are needed, the
minimum standard of practice, starting with the person and working outwards:



1 Guided conversation
Whichever way we dress it up, as statutory organisations you represent authority, power;
[volunteers] can have a fairly normal conversation, as an equal This is the starting point for
the support that the whole team provides. It is entirely led by the person, in conversation
with someone who has the time, skills and blank sheet approach to get to the core of what
will make the persons life better. It is unscripted, but is supported by guidance and
motivational interviewing skills.

2 Voluntary and community sector capacity
We need a lot of volunteers to help people make small incremental steps towards regaining
confidence. We also need community link people to back that up by creating access to the
vast range of local activities and groups that are already out there. The voluntary sector
offers more than tea and sympathy; they offer essential co-ordination, confidence building
and social connections as equals.
Current state for people who are highly dependent: inner circle of support is GP,
nurse, social worker; little connection to family and community; often isolated
Conversation and goal setting 1
Aiding recovery with help from volunteers 2
Community support 3 & 4
Care co-ordination by integrated team 5 6 7 8
Specialist support
Future state is to bring community support closer and
to shape everything around the person through:
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3 Local conversation
Its not so much about where we arrive, but that we develop solutions together
If the guided conversation is the starting point for the individual, then this is the starting
point for the local population. We held a number of workshops with local people along the
lines of come if you are interested and bring anyone else who might be. These are essential
to a mutual understanding of what we are trying to achieve and how we might do that
together. The Local People Local Conversation group is the main driver of communication
for Penwith Pioneer. We have learned that messages need to be authentic and locally
owned if they are to resonate with that population.

4 Mapped community network
It spoke to me of a latent energy in the community that I have felt but never saw tapped.
The community map is an innovation for the Penwith Pioneer and has provided a way in to
the huge community resource that so far has been largely untapped and is the underlying
infrastructure that we need for a long term, sustainable impact for people to live well.
The process itself of creating the map is important to gain support and momentum among
local people and identify the key links. There is now a core group of these people willing to
act as contacts to connect others with whats going on in their area. The community map is
now owned by and will soon feature in the Cornish media.

5 GP locality group buy-in
We came to this a little later in the day than we should had done, something thats already
been addressed as we extend into the East. Locality GPs are the drivers for the Living Well
approach and need to be involved from the start. We are aligning the Penwith Board
meetings with the Penwith Locality meetings to encourage greater cross-participation.

6 Know your population
We learned that a pragmatic approach works best. First, agree the cohort criteria. Then use
a risk stratification tool as a starting point and apply local knowledge about the practice
population to refine the list. Its important to keep it simple and use the voluntary sectors
knowledge about people who are approaching crisis.

7 Team working based around primary care
The strength of the team depends on genuine partnership and mutual respect. If you dont
commit to the approach, you wont get much from it. We learned that multi-disciplinary
teams (MDTs) come in all shapes and sizes and that care co-ordination is inconsistent. This is
a crucial function for bringing together the integrated care team and co-ordinating who is
taking the lead role. It is important to agree the escalation triggers so that each member of
the team, including voluntary sector workers, are clear on their role and responsibilities.
We have put together a training proposal that has Living Well values at its core.

8 Information sharing
In an ideal world wed all be using a single information system. In reality, we can find ways of
making a complicated system workable but the absolute minimum requirement is that all
agencies agree an information sharing protocol and crucially a relationship of trust is
developed. Honorary contracts with GP practices and providers are also useful tools.
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Developing the culture
We have learned that the whole is greater than the sum of the parts you need to build
relationships, develop the culture, and keep the conversation going and that takes time.

9 Practitioner workshops
Taking part has been an eye opener for me, to the power of patient focused care
Regular discussions with front line staff from all agencies are essential to understand the
vision, agree a new way of working and start to identify how that might change practice on
the ground. The workshop format creates a safe space for practitioners to talk freely and
understand each others roles.

10 Process mapping
The biggest surprise I had was the decision making [process] map that we looked at
The process map was the first output from the practitioner workshops. The group led the
discussion, identified the problems and potential solutions. This makes buy-in to the next
steps for example the Community Line proposal more likely.

11 Case studies/stories
The story that sticks in my head is a simple onebut it shows what difference can be made
People get it when they feel it. Many people have told us that case studies are essential to
their understanding of what Living Well is about and their own role in that. Case studies
help front line practitioners see the impact of their involvement and stay motivated; GPs can
see the change in their patients; providers can start to see how they might use their
resource differently; commissioners can see measurable differences in individuals and across
the cohort; staff and the wider public can feel personally connected to whats going on.

12 Communication
We need feedback, to see whats possible For a while we ran the local conversation group
alongside our communication workstream, but it started to feel like a mismatch. The Board
sent out a strong message that the messaging has to be locally owned, rooted in real
conversations, in formats that will reach a lot of different interests. The local conversation
group needs back up from people with communications expertise who can respond quickly
to help keep the message live.

13 Keeping it together
It needs enough bureaucracy to ensure you can measure whats working without making it
so bound by bureaucracy that it beings to fail and volunteers become fed up
We have learned that there is a delicate balance to keeping the approach light-footed
enough to do things differently and robust enough to keep a grip on all the various threads.
With a multi-agency stakeholder Board overseeing the approach, it can see the big picture as
well manage the individual workstreams. For a whole system approach, there must be a
mandate to act and permission to test.

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Im keen to see something happen so whats next?
We know there is a mountain to climb and for some of the next steps to happen other
people and organsiations need to take the lead. This is what we think we need to do next:

1. The front line practitioner group has identified how working practice can be improved,
to reduce costs and duplicated activity and improve the experience for everyone
concerned. To move things forward, we need:
Permission for staff to act clarity as to their level of decision making
and when they have to seek authorisation. We would like providers to
adopt the polices decision making circle and allow us to train front
line teams in this approach
Single operational management line e.g. a joint appointed role, for the
social care and community nursing staff in Penwith, Newquay and
the East, so that we can work together to improve practice
Co-location of front line teams to build effective working relationships
and foster the corridor conversations
We need providers to put some resource behind Community Line
proposal currently being worked up by the practitioners. That will
mean committing peoples time and agreement to moving resources
around so that we can get the single access point off the ground.

2. Accreditation or kite mark for volunteers (not just those who formally volunteer through
Age UK or Volunteer Cornwall) so that we can overcome the trust issue and open up
referral pathways to the support infrastructure identified through the community
mapping we would like the local community to lead this.

3. A consistent approach to care co-ordination and team working needs to be agreed in
each locality, whether with support from our training proposal or through some other
means. It is a core function and it needs to be supported if we are to improve care co-
ordination. This should include trusted assessors who have the skills and permission to
carry out assessments on behalf of all agencies involved.

4. Providers of specialist nursing and care teams need to work proactively with volunteers
to open up direct referral routes. We can help by being clearer about the potential for
improving health outcomes for people through this approach and giving assurance over
the level of training in self-management for specific conditions. We can help raise
awareness of specialist skills across local teams ensuring we get the right person to act
at the right time.

5. The emotional response to change needs to be fed. We are creating an open access
resource our knowledge bucket that will include all of the embedded tools and
documents from this report, as well as the output from over 30 Learning History
interviews; regularly updated FAQs, presentation materials and case studies.

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Final thoughts
Taken from the Learning History interviews, these are some of the reflections from people
who we asked, how does it feel?

The biggest surprise I had was the decision making [process] map that we looked at across
all sorts of agencies that impinge upon patients. When that rolled out, literally, across a
whole room, and you could see some decision making steps required dozens and dozens of
phone calls to get things done, it just summed up the frustrations to the point that I let my
head fall on the desk loudly.
I think Ive always got it because its a no-brainer that if you focus on a cohort that is
vulnerable and at risk then there needs to be a whole system approach to supporting that
a scatter gun approach doesnt work, its what health and social care have done for years. As
soon as the idea was mooted I was a big fan, I think its a great idea. Whether the social
agenda thats described is the panacea for all problems of the health services is a different
questions and Im not remotely convinced by that.
Im very excited. Its terrifying as well. Its a very high risk strategy in the sense of plotting a
journey without the evidence thats needed to make you feel confidence that the direction is
the right one.
For me the outside NHS perspective has been most beneficial. Working with the voluntary
partners has made me challenge my leadership skills, become a stronger leader in managing
demand, leading localities and transforming communities.
I thought it was a tall order, it was a particularly high target 1,000 people. It worried me
that staff would be focussed on getting the people into the programme rather than doing
the work that makes a difference.
If feels like we are running before we can walk. We havent reached our potential yet [in
Penwith], its all still very new and we are ironing out the creases feels like we are moving
on before the creases are out.
Initially I was a bit sceptical while I got the vision, I wasnt sure that others would, that it
might just die a death. It hasnt fallen flat and people are trying to make it work. I think
things were a bit slow to get going and we were all finding our feet.
The only aspect that is uncomfortable for me is the worry that too much is attached to the
Pioneer/Living Well as a project within KCCG. It isnt going to solve all of our problems and
we should be totally honest with the public about finance and the difficulties we have. Only
when we do that will people understand that we cant solve all the problems.
I just want to see something more concrete, I want some action on it now. I want it to be
permanent, we do so many trials and projects then we just lose it.
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Thanks
Penwith Pioneer Project Team
James Pratt
Learning History interviewees and interviewers