Family Mentor Service podcast

The Family Mentor service is a free service for families living in Nottingham. It is run by Small Steps Big Changes, which is hosted by Nottingham CityCare. Family Mentors are a highly trained paid peer workforce that deliver the Small Steps at Home programme of child development and preventative health support to parents of 0—4-year-olds.

Family Mentors are parents or grandparents from the communities they support who can give advice and support on lots of different topics. They can support the whole family adapt to life with a new baby. Their advice is based on the latest evidence in child development.

In our latest ICS podcast, Dr Kathy McLean (Chair of Nottingham and Nottinghamshire Integrated Care Board) chats to Donna Sherratt (Head of the Small Steps Big Changes Programme) and Rachel Mabbott (Family Mentor) about the Family Mentor Programme in Nottingham.

To find out more visit:

www.smallstepsbigchanges.org.uk

www.nottinghamcitycare.nhs.uk

Monthly shout-out to the Community Matron team at Nottinghamshire Healthcare Trust

Congratulations to the Community Matron team at Nottinghamshire Healthcare Trust for winning this month’s shout-out.

The team works across Rushcliffe, Nottingham North and East and Nottingham West supporting older people living with moderate to very severe frailty. They help people to maintain their independence and remain in their chosen place of care. This improves the health outcomes of those living with frailty and allows for access to healthcare that would be difficult or impossible for this housebound population. Provision of expert, proactive case management prevents unnecessary hospital admissions, reduces attendance at A&E and allows patients to remain living independently in their own homes, which is what patients tells us they want.

The Community Matrons utilise a Comprehensive Geriatric Assessment approach to their care delivery which includes tackling issues such as falls, polypharmacy, advanced care planning, social care, mental health, maximising long term condition control and social isolation. This proactive caseload management is achieved through successful liaison with social services and voluntary organisations and working closely with primary, mental health and secondary care.

The matrons are the lynch pin to co-ordinate all the services that a frail, older person may require, ensuring that services work together to achieve the patient’s goals. Working within a multi-disciplinary team, personalised care plans are discussed and evaluated in order to support a person’s health and social care needs. This illustrates the principles of prevention, equity and integration between health and social care.

Read about how they are making an impact on people’s lives:

Case study 1
“I will be 92 in June this year and I’m totally disabled with a rare form of myositis. My wife is nearly 85 and was registered as partially sighted some years ago, since then here eyesight has continued to deteriorate.

“I just came across the Matron Service when I was discharged from hospital late November 2022, I had been in hospital with pneumonia. The matron came to my home to see how I was coping. She gave me a thorough physical examination and gave me advice with coping with the after-effects of my condition. She spent an hour with me and I was very relieved that the health services were looking after me. She returned at about two weekly intervals on a further three sessions to see how I was coping.

“I value her services as she is readily available for a home visit and very knowledgeable, and has time to deal with any problems or queries I may have. If it wasn’t for this valuable service, I would be requesting a visit from a doctor who might not be able to spend so much time with me. I regard this service as vital for people in my situation.”

Case study 2
“We have had the wonderful Community Matron, visit us over the last four months and she has made such a difference in our lives. My husband has a lot of illnesses with his diabetes, heart failure, COPD and kidney problems it was all getting too much for both him and me. The matron came to see us and explained that she was wanting to support us in looking after his health and to try and improve things where we could.

“She took over two hours on our first appointment and we discussed everything, she examined him head to toe and then we discussed a plan of action. She also helped us with sorting hospital appointments and that was such a help. She asked me how I was and directed me to carer support if I wanted to have it.

“The matron has been a wonderful, caring, kind and compassionate nurse. She is always on the end of the phone if we need her and nothing is too much trouble. She has sorted issues with medications, she ensured that services linked together so my husband got things he needed and she reassured him. She really listens to us both.

“We have been able to plan for the future and make sure that his wishes are written down and that was really good and when she left my husband said he felt calmer and listened to.
I can’t praise her enough really, she is a very special person with so much knowledge and expertise and I think she is a rare find in this NHS.”

Case study 3
“Our Community Matron supported us to navigate through a decline in health of my mother-in-law through Parkinson’s over the last year or so. The matron anticipated her care needs and worked with many stakeholders and services to secure the best possible care in a timely, caring and professional way.

“Our Matron always put the wishes and needs of our loved one first and gave them and us as her carers a voice and a path through the challenging months before her eventual passing in December. She took time to get to know our loved one, building a relationship with her, the carers and our family. This allowed her to understand patient need and advocate for this and it built a very high level of trust for us all. We felt so supported throughout, we didn’t even know what we needed or what was available, and the Matron was able to gently work through what was ahead and ensure documentation, drugs, support services were aligned. This relieved a huge stress on us as a busy family, we were prepared for next steps and when the end came it was exactly as our loved one wanted – to be at home and in no pain. This brought an enormous sense of comfort at a very difficult time.”

Monthly shout-out to Rebecca Sandy

This month’s shout-out goes to Rebecca Sandy, Lead Clinical Specialist Occupational Therapist (OT) who is on secondment with Nottinghamshire Fire and Rescue Service from Nottinghamshire Healthcare NHS Foundation Trust. Rebecca has worked with partners across fire services to develop a new and innovative national CPD resource to reduce the risk of accidental fires in the home.

The resource Rebecca has developed is available as a presentation and workbook that can be used by an individual or as part of a team. It highlights key areas where OTs can incorporate fire prevention in their practice, including enhanced assessment of cooking safety, risk enablement with ‘safer’ smoking (where the person does not want to quit smoking), safer access arrangements, and education and advice for families and carers. The resource is designed to increase the confidence of OTs with addressing fire safety and developing closer partnership links with the Fire and Rescue Services.

Rebecca said, “Occupational Therapists have an important opportunity to identify and reduce fire safety risks within our community. We are already working with patients who face a higher likelihood of being affected by accidental home fires, and we can play an important role in helping them and their families and carers to create a safer environment.”

Rebecca’s role with the fire service includes providing specialist assessments and interventions to those at the highest risk of having an accidental fire in their homes, as well as embedding an understanding of health, client-centredness and positive risk-taking within the Prevention team in the fire service.

The new fire safety resource is available to be downloaded from the Royal College of Occupational Therapists website by members of the organisation.

Kathy’s blog: lifting our gaze

‘Every person enjoying their best possible health and wellbeing’ is our shared ambition for people who live in Nottingham and Nottinghamshire.

A year ago we launched our Integrated Care Strategy, which describes what we will do to achieve this ambition over the next few years. We have been reviewing and updating our strategy, which is a timely reminder that our success as partners in an Integrated Care System hinges not only on day-to-day improvement in the delivery of health and care but also on our ability to lift our gaze towards strategic planning and transformation.

We know there are a range of important operational issues that are taking up so much of everyone’s time, such as improving the timeliness of pathways for urgent and emergency care, reducing the number of people waiting for treatments, surgery or cancer or improving access to general practice. These things are critical for our patients but are insufficient by themselves. We need to carve out time to think beyond the daily work, so that we can support changes which will help people to be well physically and mentally. By working together across all our partners, at local neighbourhoods and across the wider system we have the opportunity to be bold and make transformative changes that will not only improve patient outcomes but also bolster the resilience and sustainability of our health and care system as a whole.

We need to keep in mind our joint vision for health and well-being. Our Integrated Care Strategy sets this out with the key principles of prevention, integration and equity.

Our Strategy becomes the guiding light in dark times, meaning we can tackle tactical issues in a strategic manner and focus on the bigger picture rather than only on the immediate issues in front of us.

One of our real strengths as a system is our joint work on data and analytics and we will shortly be able to measure the impact of our Strategy in a granular way to help us track progress.

The responsibility sits with all of us to make a difference and to find the time to make those small, incremental moves towards a more equitable, integrated and preventative health and care system. There are lots of ways that you can be part of this change – whether it was through joining in the conversation at our ICS Partners Assembly, or through making a nomination to our Health and Care Awards or by taking the time to read and digest the Integrated Care Strategy.

But really, the change starts with all of us, every day. What questions can you ask about how our services are arranged and delivered that will make them more efficient and effective? How can you be part of the positive challenge to think about how your part of the health and care system links with the other parts?

Our ultimate goal is not merely to manage illness but to promote health and wellbeing in its fullest sense, supporting our communities to enjoy the best possible health and wellbeing. You can be, and in fact must be, part of delivering that, no matter how hard it seems to find the time.

Dr Kathy McLean

Chair of the Nottingham and Nottinghamshire Integrated Care Partnership

Monthly shout-out: CardMedic Maternity and Neonatal Pilot

Our shout-out this month goes to a new scheme which is helping to overcome communication barriers in maternity and neonatal services.

CardMedic launched within maternity and neonatal services at Nottingham University Hospitals (NUH) and Sherwood Forest Hospitals (SFH) in March. CardMedic is an innovative digital communication tool which improves communications between healthcare staff and patients regardless of language barriers, visual, hearing and cognitive impairments.

Communication barriers can lead to health inequalities and there is a wealth of evidence that associates language barriers with adverse events when accessing healthcare services. Pregnant women who do not speak English are at greater risk of poor birth outcomes compared to their English-speaking counterparts. Poor communication can also have a negative impact on a woman’s experience. The use of CardMedic aims to reduce health inequalities, improve personalised care, enhance quality of care, and improve patient safety.

Nearly 250 people have registered with the service and early feedback has been resoundingly positive. In one example, a registrar was able to communicate effectively with a Vietnamese-speaking service user during a night shift about induction of labour.

A special thank you goes to Siobhan Buxton in the ICB Maternity Commissioning Team, Gemma Boyd (Consultant Midwife and Professional Midwifery Advocate at SFH), and Debrah Neale (Matron for Community Engagement and Innovation at NUH) who have been an integral part in the launch of the service.

On Day Service pilot for Nottingham City East

Nottingham City East Primary Care Network (PCN) have been showcasing a pilot project which is helping patients get urgent same day GP appointments.

The On Day Service, based at St Ann’s Valley Centre, has created extra urgent same day appointments based in a central hub that practices can utilise if they are at full capacity. The service operates 5 days a week, 10am – 3pm.

The pilot has been running since May 2023 as a partnership between the PCN and Nottingham City GP Alliance.

Data showed that residents within the PCN were the biggest utilisers of the Urgent Treatment Centre (UTC) on London Road, with approximately 11% of the population attending between April 2022 and March 2023. Evaluation of the pilot service is underway but it is expected to have reduced attendances at the UTC and supported practices to be more resilient and responsive to their patients.

Dr Kathy McLean, Chair of NHS Nottingham and Nottinghamshire Integrated Care Board, said: “I was delighted to visit the On Day service recently and spend a morning with the team. This is a great example of practices in one area working together to benefit their patients. It also fits with our principle of ‘equity for all’, as the pilot is making healthcare as accessible as possible for those communities who may otherwise struggle to get support, due to language barriers.”

62% of the residents who live in the Nottingham City East PCN area are defined as the most deprived 20% in England. It is also an incredibly diverse area with 23 different languages spoken. The area also has higher than national average prevalence of severe mental illness, depression and learning disability.

Monthly shout out: Allied Health Professionals leadership work

Our monthly shout out goes to Leanne Horsley from Sherwood Forest Hospitals Trust and Sally Knapp from Nottinghamshire Healthcare Trust for their system leadership work with Allied Health Professionals (AHPs). AHPs include physiotherapists, occupational therapists (OT), therapeutic radiographers, podiatrists, paramedics and other professions in health and care.

Leanne and Sally have worked strategically and collaboratively with a range of AHP leads to:

attract over £765,000 of investment through short term funding for specific projects
lead staff development opportunities across seven different AHP groups
grow practice placement capacity
support four different professional apprenticeships helping unregistered staff take up new roles as AHPs
lead the Nottinghamshire senior leadership team and OT system-wide integrated rotations with a suite of resources and blueprint for this to be replicated
develop a toolkit for OT services that will be used nationally to establish innovative and robust rotations for newly qualified occupational therapists that encompass health and social care organisations, across physical and mental health settings
produce and implement an AHP support worker development toolkit to help provide a full and accurate picture of the unregistered workforce, which is crucial for workforce deployment, planning and future staff development
create an AHP educators’ community of practice to increase clinical placements in the private, independent and voluntary organisation sector
the possibility of an AHP legacy mentor programme where experienced AHPs, usually in latter stages of their careers, provide coaching, mentoring and pastoral support to staff newly appointed into Health or social care

Suzanne Avington, Associate Director for AHPs at Nottinghamshire Healthcare Trust, said: “Leanne and Sally are forward thinking, proactive innovators. Their pursuits build on national AHP and health policy and direction which they continue to shape to the needs of the ICS. Their work and their approaches inherently reflect the three principles of the Integrated Care Strategy. They epitomise working across organisations, identifying, and acknowledging the diversity and unique offer of AHP workforce across health and social care to grow and develop a future generation of staff that are multiskilled and adaptable. With understanding and curiosity, they look to test how inclusive our offers are to educate and train staff in order to develop the capacity and capability of a diverse workforce that is reflective of the communities we serve.”

Monthly shout out to – the Smokefree Team at Nottinghamshire Healthcare NHS Foundation Trust

Congratulations to the Smokefree Team at Nottinghamshire Healthcare NHS Foundation Trust, who have been awarded the ICS monthly shout-out for their work to support patients with mental illness to stop smoking.

The work of the team includes:

Setting up a smokefree service within inpatient mental health units, utilising a holistic, person centred approach to smoking cessation and harm reduction.

Designing and facilitating the use of bespoke, educational resources and materials to aid distraction techniques to manage nicotine withdrawal. These have been produced in an easy-read format and other languages and also flash cards for non-verbal patients. The packs have been shared with other mental health trusts nationally.
Delivering bespoke training sessions to patients, directly on the ward, educating on different types of Nicotine Replacement Therapy, alongside the benefits of a harm reduction approach for patients who are not ready to quit smoking.
Designing and delivering speciality training modules to 2500 staff working in patient facing areas such as coffee bars and receptionists in GP surgeries.

Delivering a suite of support and training within the Specialist Services directorate, including Child And Adolescent Mental Health, Mother and Baby and also within the prison service.

The team is an example of best practice nationally and it supports other mental health trusts with the implementation and facilitation of smokefree services, including the writing of their smokefree and vaping policies and procedures.

System Analytics Intelligence Unit podcast

The System Analytics Intelligence Unit (SAIU) was set up on 4 July 2022. This followed the COVID pandemic, where as a system we identified the huge value and benefit of integrated working with our systems data/intelligence and analytical partners to better identify and support the health and care of our population.

In our latest ICS podcast, Dr Kathy McLean (Chair of the Integrated Care Board) chats to Maria Principe (Director of Clinical Transformation and Effectiveness, ICB), Sergio Pappalettera (Contract and Information Manager, ICB), Stephen Wormall (GP lead for health inequalities mid Notts, ICB) and Chris Packham (Associate Medical Director at Nottinghamshire Healthcare Trust) about how the SAIU is offering a more granular and detailed understanding of what’s happening in and across our system.