Key priorities

To make sure we are strong for the future we are balancing operational and clinical excellence in our services with innovation. This means that we will:

• Blend our expertise so that we can provide more ‘whole person care’ for people with physical and mental health multi morbidity
• Partner with other organisations to find the best solutions to the big demand, workforce, and affordability challenges
• Continue to be an innovator using data and technology, ensuring that modern technology helps our clinicians to do their jobs but also makes it easier for people to access the care they need
• Explore and utilise the M-RIC research and innovation partnerships which will bring new innovations in treatment for our service users and patients.

We want to use our unique blend of all-age services to become more preventative with a focus on people’s total health and wellbeing needs.  Across our organisation we have a tremendous foundation to build on – to develop more coordinated care which meets people’s mental health, physical health, learning disability and addictions needs. 

We call this approach Whole Person. This means providing support for their physical health, mental health, learning disability and addiction needs in a coordinated way, removing the need for so many separate appointments.  It also means having a greater focus on prevention and earlier intervention, using data and insight to understand peoples’ needs and take a ‘whole family’ approach across our services.

We will use data and technology to make our services more targeted, effective and personalised, giving people greater control of their health and extending the reach of our specialist teams. This will include:

• A new single data platform to strengthen business intelligence
• Undertaking a training needs analysis to inform and build staff skills, confidence and knowledge around digital technology
• Implement digitally enabled care opportunities in our service lines.

Workstream update (July 2024)

We have started engagement to further understand what ‘Whole Person’ means in practice, building on our analysis work and have:

• Used shared data from health and care to understand more about the needs of people who present in our services with a complex mental health, physical health and social needs
• Identified the scale of opportunity to reduce duplication and provide more joined up care for service users and carers who are seen in both our physical health, mental health services and other services
• Started engagement with clinical teams about what ‘whole person’ means in practice for them and how we will measure we are providing care for people’s total health needs
• We are continuing to gather and share case studies and examples of great practice in our services in meeting people’s holistic needs.

This workstream is all about improvements that link into the North Mersey System plans that positively effect:

• Attendance avoidance into emergency departments by working with partners to ensure robust alternatives are in place and easy to access (Stay at Home)
• Admission avoidance from emergency departments with a focus on alternative options like home with urgent community response, same day access to specialty clinics including frailty, rapid diagnosis and decision making (Keep me at home)
• Patient flow through the hospital once patients have been admitted and aim to reduce the length of time they are in hospital and the probability of unnecessary harm (Get me home)
• Appropriate and timely discharge to a patient’s normal residence as much as possible and limit the requirements for long term care (Stay at home).

Workstream update (July 2024)

Four “Test of Change” priorities as an output of an avoiding attendance and admission workshop in June:

• Frailty – diversion and changes to the model
• Processes in and out of Single Point of Contact making sure the following principles are core (simple, responsive, clear and accountable)
• Zero referrals rejected through Single Point of Contact as a perfect care goal.
• Agreement of a risk positive framework. Transfer of Care Hub mobilising its operational framework and working on the aim of more patients leaving hospital quicker and more on pathway 1 (home with care) rather than pathway 3 (long term care)
• Walk-in Centre and Urgent Treatment Centre model being further developed to ensure a consistent offer and maximise their impact for primary care and emergency departments.

The Intermediate Care transformation focusses on enabling and delivering improved, consistent pathways to step up and step-down care. This includes taking a system-wide approach ensuring timely and appropriate access to intermediate care beds and support for people in their own homes to enable people to stay well, safe and independent for longer.  The main focus is to develop more step-up pathways in conjunction with the development of a Hospital@Home service model.

Workstream update (July 2024)

• Standardisation of home-based intermediate care offer being taken forward
• Reduction in length of stay for particular cohorts of patients, pathway by pathway. Our first big success is the orthopaedic pathway that has seen an increase in patient flow and a decrease in the length of stay within Longmoor House and on the orthopaedic wards with Liverpool University Hospitals NHS Foundation Trust
• More patients are going home from intermediate care beds to their own homes with little further health input
• Clinical deterioration meetings to review all patients who have deteriorated within 72 hours of admission now live (positive safety tool).

We are working with our care home staff, residents, families and other partners to deliver services in care homes in a collaborative way so that together we can provide personalised care, improve outcomes and promote independence for people living in care.  Our work will recognise the life course of people who live in a care home and promote the ethos of living, ageing and dying well and ensure that we develop a model that is consistent and standardised across all the places the Trust provides support into care homes.

Workstream update (July 2024)

• We have brought teams together that are delivering support in care homes and started to have the right conversations and raise the profile of the work we are doing to support care home residents and the Enhanced Health in Care Homes (EHCH) framework
• Explored our workforce model for care homes to support a consistent integrated offer across places, including community matrons, AHPs, mental health and learning disabilities
• Reviewed how we collect data for the work we do within care homes, and we have developed a standard EMIS template to support consistency in what we are measuring and reporting focused on outcomes
• Worked with our commissioners and other partners in Liverpool to review the EHCH specification with a view to potentially using this as an exemplar we could use across other ‘places’ where we deliver services
• Our learning disability and autism leads and matrons have been exploring how we can deliver an integrated learning disabilities/physical health model within care homes to support residents with learning disabilities.

This improvement work has a real focus on the community mental health provision to complement the urgent care and inpatient service lines. The team are looking at:

• Standardisation of practice
• Improved access (working towards a referral to treatment time of four weeks)
• Use of digital to improve efficiency and effectiveness as well as the patient experience
• Much more cohesive and partnership working with the voluntary sector to maximise the assets of the communities
• Moving away from CPA to personalised care.

Workstream update (July 2024)

• A well-developed programme of work that has been delivering for the last four years
• Key areas include access to our services, transition from our services and intervention-based care
• Benefits achieved so far include:

1. Improved relationships with our external partners
2. Work with primary care including more than 50 additional roles reimbursement Scheme (ARRS) practitioners recruited
3. Move away from CPA to personalised care
4. Caseload management 24% reduction
5. Waiting list for first contact reduction from circa 60 weeks (Sept 2020) to under seven weeks average (Oct 23) Development and integration of a Lived Experience team.

Our Learning Disability and Autism Strategic plan (LINK to plan) sets out ambitious goals for 2024 to 2028 which are focused on transformation of the delivery of care and treatment with the aim of reducing health inequalities, improving access and health outcomes.

This is our first, Learning Disability and Autism Strategic Plan, co-written and co-developed with people with a learning disability, autistic people and carers. The plan focuses on the transformation of the delivery of care and treatment with the aim of reducing health inequalities, improving access and health outcomes taking a whole person approach.  The main transformation priorities are improving support in the community, reducing avoidable admissions, and enhancing access to all services through reasonable adjustments, training, technology, and by working together.

Workstream update (July 2024)

• Our co developed and co-written strategic plan was launched successfully at the Clinical Senate
• 11 priority areas to be driven forward to ensure inequalities are minimised, improved access, enhanced focus on whole person care and patient experience and a well-trained workforce
• Measures of success have been identified and governance in place to drive forward the changes.

The End of Life Care transformation is to ensure high quality, person-centered care is offered to all our service users/patients in the last year of life. We will make sure improved delivery of community and specialist services and enable access for our patients and service users to end of life support across all the places we work.

Workstream update (July 2024)

• Collated a single trust-wide Palliative and End of Life Care (EOL) Framework to provide an overall vision for providing consistent high-quality person centered EOL care, aligned to NHS England and the Ambitions Framework
• Mapping current internal process for enabling access to specialist EOL care from our Mental Health, Secure and Learning Disability and Autism services
• Started discussions with our partners around developing a single point of access across all our places
• Developing standard procedures and processes to support patient and carer experience and appropriate bereavement support
• Developed Mersey Care Citizens Charter for patients and families at the End of Life, aligned to national strategies to support improved patient/ carer participation and experience.

We are working to develop a model of care that provides access to physical health services for all service users/patients who need an inpatient stay in any of our mental health, addiction or learning disability and autism services regardless of where they are provided. Our model, once developed and implemented, will ensure a consistent, person-centered approach to delivering improved health outcomes for in-patients across Mersey Care. This includes mapping and establishing pathways for inpatients in each place to enable timely access and support around their physical health needs.

Workstream update (July 2024)

• Undertaken a baseline analysis of all the templates we ask our staff to complete when a service user is admitted into one of our inpatient beds as well as the questions our staff ask of service users
• Developed a draft standardised inpatient model/pathway which can be used for all our inpatient units – mental health, learning disabilities, addictions and secure care.

We will transform how services for children, young people and their families are delivered across our footprint, with a focus on prevention, early help, and targeted support, particularly for families with complex needs. The service model will be devised after insight and engagement with communities, patients and service users, public and partner organisations so that we can ensure transformed services reflect emergency needs and use of innovation.

Our vision is to work in partnership to improve the health and well-being of children, young people and their families through the provision of evidence-based care across services including transition points, delivered by a highly trained and well supported staff.

Workstream update (July 2024)

Work has been scoped for the following priorities that will be taken forward over the next 12 months:

• • Simplified Point of Contact
  • Workforce development
  • New model of care to support most appropriate care package is accessed
  • Telehealth and our digital offer
• Building the foundations and ensuring basics are established
• 18 to 25 year old transitions.