Pillar 4: An integrated health and care system

Cheshire West 'Place' is one of nine places within the Cheshire and Merseyside Integrated Care System (ICS). The ICS's purpose is to ensure that the people of Cheshire and Merseyside become healthier and continue to have access to safe, good quality and sustainable services. The ICS also has a key role to play in reducing health inequalities, through the CORE20PLUS5 programme but also more broadly, for example, though its sustainability and Green Plans.

The ICS will be as a statutory body on 1 July 2022. It will include a new NHS body called NHS Cheshire and Merseyside Integrated Care Board (ICB) and a statutory Integrated Care Partnership (ICP) called NHS Cheshire and Merseyside Health and Care Partnership.

The Cheshire and Merseyside ICB will be responsible for the day to day running of the NHS in Cheshire and Merseyside, including planning, and buying healthcare services and taking over the functions of the Clinical Commissioning Groups, which will be abolished when the ICS gains legal status. The ICB will arrange for some of its functions to be delivered and decisions about NHS funding to be made in its nine Places, through Place-Based Partnerships. The ICB will be accountable for NHS resources deployed at Place.

The Integrated Care Partnership (known as Cheshire and Merseyside Health and Care Partnership) will provide a forum for NHS leaders and local authorities to come together as equal partners alongside other stakeholders from across Cheshire and Merseyside. The Cheshire and Merseyside Health and Care Partnership will generate an integrated care strategy to improve health and care outcomes.

Health and Wellbeing Boards (based on a Place/Local Authority footprint) will continue to develop the Joint Strategic Needs Assessment and the Health and Wellbeing Strategy. Unlike other Places in Cheshire and Merseyside, for Cheshire West, this Place Plan is the Health and Wellbeing Strategy.

Like other Places, the Cheshire West health and care system is tackling increasingly complex health issues experienced by our population. The system was not designed for people with multiple conditions using multiple services. The complexity of people’s health issues today means services need to be designed and integrated around an individual’s needs rather than around separate organisations. We also recognise the key role of the Community Sector in delivering health and care services. We want to work with people locally to jointly shape services, improve the quality of care, decrease health inequalities, and make sure that services are financially sustainable for the future.

Partners across the borough, including the NHS, Local Authority, the Community Sector and Healthwatch are working to integrate care, with a focus on prevention, supported self-care and delivering personalised care closer to home. In this way, local people will benefit from services which are easier to access, better organised, more joined up and, most importantly, targeted to their needs. The aims of a more integrated approach are to:

• Improve population health
• Improve healthy life expectancy
• Reduce health inequalities
• Transform the experience and quality of care
• Ensure the sustainable delivery of health and social care

Our nine Care Communities are key to the success of this work. Care Communities are about the local community, bringing together organisations that aim to transform, develop, and deliver community health and social care services. They include the local GP network (known as the Primary Care Network), and the wider primary care team, including Community Mental Health Teams, District Nurses, Occupational Therapy, Community Physiotherapy, Midwives, Dentists, Opticians, Pharmacists, and other community specialists. There is also representation from local people themselves.

Our Care Communities take into account the whole community. This includes others who have a significant role such as Social Care, Public Health, Education, Town Planners, Local Employers, Third Sector, Local Sports Groups, Parish Councils and of course the Communities themselves. The Care Communities arrange care and provide innovative health solutions in partnership with the local community that suit the needs of a whole population and takes the views of all these stakeholders into account.

We will:

• Develop and publish a more detailed action plan, to sit under this Place Plan, with joint leadership from health and care, based on local data, intelligence and by taking resident views into account.
• Continue to develop our approach to population health management, using data and analytics to prevent ill-health, address health inequalities, and identify those residents who are at higher risk of their health deteriorating, enabling us to deliver preventive interventions.
• Pursue environmental sustainability and health equity together.
• Continue to develop and formalise integrated ways of working across the Local Authority, NHS and other providers in Cheshire West.
• Share Local Authority and NHS prevention budgets and greater NHS percentage investment in upstream, prevention of ill-health, with annual monitoring of spend.
• Join up care pathways across the Council, the NHS, and the Community Sector.
• Redesign local services as necessary.
• Develop closer relationships with the residents in our communities.
• Support the development of our nine Care Communities
• Strengthen involvement of the Community Sector in care community delivery, supported by increased and longer-term funding, to build community resilience.
• Tackle the backlog of elective care, reduce long waits and improve performance against cancer waiting times standards – all resulting from the COVID-19 pandemic.
• Continue to deliver the NHS COVID-19 vaccination programme and meeting the needs of patients with COVID-19.
• Improve the responsiveness of urgent and emergency care and build community care capacity– keeping patients safe and offering the right care, at the right time, in the right setting.
• Improve timely access to primary care.
• Improve mental health services and services for people with a learning disability and/or autistic people - maintaining continued growth in mental health investment to transform and expand community health services and improve access.
• Exploit the potential of digital technologies to transform the delivery of care and patient outcomes - achieving a core level of digitisation in every service.