ITEM 8 Getting It Right For Everyone(GIRFEF)
North Lanarkshire Council · 22 November 2023
Back to Health and Social Care Integration Joint Board — 22 November 2023 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 REPORT Item No: 8 SUBJECT: Getting It Right For Everyone TO: Integration Joint Board Lead Officer for Report: Trudi Marshall, Nurse Director, Health and Social Care North Lanarkshire Author(s) of Report Margaret Flavell, Senior Manager Adult Social Work DATE: 22 November 2023 1. PURPOSE OF REPORT This paper is coming to the IJB for: For approval ☐ For endorsement ☒ To note ☐ 2. ROUTE TO THE BOARD This paper has been: Prepared: ☒ Reviewed: ☐ Endorsed: ☐ By: the Health and Social Care Partnership Strategic Commissioning Plan Programme Board. 3. RECOMMENDATIONS The Board is asked to: (1) Note the participation of Health & Social Care North Lanarkshire in the national Getting it Right for Everyone (GIRFE) pathfinder programme, focussing on older people and adults living with frailty. (2) Endorse and the approach and planned work to develop GIRFE across North Lanarkshire.
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2 (3) Agree a further update on the progress of the GIRFE work to be brought back to a future meeting of the Board. 4. VARIATIONS TO DIRECTIONS? Yes ☐ No ☒ N/A ☐ 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 BACKGROUND 5.1.1 Health & Social Care North Lanarkshire has a strong track record of integrated working. North Lanarkshire introduced the first multidisciplinary Hospital at Home Team in Scotland and are currently building on our existing best practice in adult services by embedding a Home First approach to hospital discharge through the establishment of a Home Assessment Team. In addition, to this we have implemented Integrated Rehabilitation Teams, along with our addiction teams. Over the past 2 years we have been piloting geriatrician supported multi-disciplinary reviews within GP practices and Care Homes as highlighted in the recent Chief Medical Officer report. We have a strong third sector which promotes welcoming communities, encourages connections and supports people in a range of ways when they require some assistance. 5.1.2 The Plan for North Lanarkshire sets out a vision for town and community hubs whereby citizens have easier and earlier access to support and services in their local neighbourhood or town. It takes a place based, whole systems approach that mobilises all assets within a community, promoting equity and increasing people’s control over their health and lives. 5.1.3 The NLHSCP Strategic Commissioning Plan further reinforces this by seeking to build on community capacity to take action together through collaboration and partnerships where approaches connect people to community resources and increase active participation through activities and volunteering. Concurrently, several transformational change programmes are underway and a number of these, in particular the refresh of the Home Support Redesign, Home Assessment Team/Discharge without Delay, Integrated Day Services Review, Community Alarm Review, Integrated Equipment and Adaptations Service Review and Community Nursing Review are intrinsically linked to the GIRFE pathfinder project. In addition, NHS Lanarkshire is currently developing a Strategy for Prevention and Management of Frailty as part of NHS Lanarkshire’s ‘Our Health Together – Living Our Best Life in Lanarkshire’ strategy. A key aim of the strategy is supporting older people to remain well and active within our communities.
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3 5.2 Getting it Right for Everybody 5.2.1 Getting it Right for Everybody (GIRFE) provides a framework and a set of principles for person centred and community centred ways of working as outlined below: GIRFE is a proposed multi-agency approach of support and services from young adulthood to end of life care. GIRFE will help define the adult’s journey through individualised support and services and will respect the role that everyone involved has in contributing to collaborative care and support planning, review and personalised interventions. Too often, adults and their families are excluded from assessment and support processes by complex bureaucracy. GIRFE is about providing a more personalised way to access help and support when it is needed – placing the person at the centre of all decision-making that affects them to achieve the best outcomes, with a joined-up, coherent and consistent multi- agency approach regardless of the support needed at any stage of life. 5.2.2 GIRFE: builds on existing adult best practice and Getting it Right for Every Child (GIRFEC) provides a national practice model to embed inter-agency working. does not replace the framework for Community Health and Social Care Integrated Services but provides a model to deliver the framework that supports person centred outcomes. GIRFE Principles 5.2.3 GIRFE is: Focused on individual care needs – it ensures that every person is empowered and involved in multi-disciplinary decision-making and the support available to them. Based on an understanding of the physical and mental well-being of individuals in their current situation – it adopts a holistic approach to ensure
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4 that individual needs are considered, and that appropriate support is provided while acknowledging that a person’s needs will vary over time. GIRFE Pathfinder projects 5.2.4 GIRFE pathfinder work will be tested and developed in local areas, with practitioners and with the people the initiative is designed to benefit, to understand how it will be interpreted and implemented in different contexts. 5.2.5 The Pathfinder programme is taking a co-design approach with: GIRFE Learning Networks to support a national practice model. GIRFE Design School - a support model which can help teams to come together, get ready for co-design work, and engage people with lived experience on a specific policy area, problem exploration or redesign challenge. 5.2.6 There are 11 place-based pathfinders across Scotland aligned to five thematic areas: i. People in prisons ii. People in addiction services iii. People registered at Deep end GP Practices iv. Families with multiple and/or complex needs and young people in transition from GIRFEC to GIRFE v. Older people and frailty 5.2.7 The North Lanarkshire GIRFE pathfinder links to a range of national policies including Home First, Discharge without Delay, Realistic Medicine, Self Directed Support, Unscheduled Care and reducing the number of people whose discharge from hospital is delayed. Reshaping Care for Older People continues to influence our local work as does the Health Improvement Scotland Frailty Change Package and national and local Mental Health and Wellbeing Strategies. It is also a priority outlined in the Winter Planning Business Case agreed by the Integration Joint Board in February 2022. 5.2.8 GIRFE will support the person-centred, integrated and multi-agency approach required to support individuals. Within an overarching commitment to self- direction this will improve access and embed practice in shared decision- making and promoting self-determination, encouraging those with lived experience, including unpaid carers and families to be equal partners in their care and support. This is aligned to the Human Learning System approach. 5.3 Aims and objectives of the North Lanarkshire GIRFE Pathfinder To agree a vision for GIRFE for Older People & Frailty in North Lanarkshire. To establish a multi-agency approach of support and services for older people and adults living with frailty.
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5 To define the person’s journey through individualised support and services, respecting the role that everyone involved has in contributing to shared care and support planning, review and personalised interventions. To create a single point of access within localities to ensure holistic assessment of people and coordination of services to support them achieve their personal outcomes, enabling them to be as independent as possible and live their best lives. To ensure that, when people are admitted to secondary care (planned or unscheduled) their journey meets GIRFE principles. To embed a Home First approach to enable timely discharge from hospital and prevent unnecessary admission to hospital or premature admission to long term care through the establishment of multi-disciplinary assessment and coordinated care, rehabilitation and support at home or closer to home: Rapid access to the treatment, rehabilitation and support that people require to enable them to return home from hospital at the right time or receive their acute care and rehabilitation at home or closer to home as an alternative to emergency admission to hospital. Time-limited support and rehabilitation to enable an assessment of each person’s immediate and longer-term support needs in their own home, optimising use of personal and community networks and reablement to support recovery and optimise wellbeing and independence. A designated workforce, equipped with the appropriate education, competence and capability, focussed on maximising functional ability in the home environment by providing proactive anticipatory care, timely multi- disciplinary assessment and a rapid community response. An agreed care plan based on what matters to the individual and shared decision making. An integrated, multi-agency care coordination and review process. Clear pathways and a range of resources to support unpaid/family carers. Embedding a technology first approach to promoting independence and connectedness. To take co-creation approaches to the design of support and services. To identify if services could be strengthened through a community hub model and, if there are opportunities presented with the implementation of the Newmains & St Brigid’s Community Hub (and linked network of support) as an early adopter. 5.4 Project plan 5.4.1 Pathfinder activity will be divided into two phases: Phase 1: An Engagement Plan will be developed by each Health & Social Care Partnership for their pathfinder. Journey Maps, developed from intial Engagement Sessions with service users within each pathfinder, will inform a National Sensemaking Process, which will determine ‘How Might We…’ statements for the second phase of Engagement.
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6 Phase 2: The Engagement Plan will be updated following involvement with the National Sensemaking Process and will detail further engagement sessions with people with lived experience to co-design ideas and concepts. A further Sensemaking Session will take place following submission of each idea/concept. 5.4.2 The detailed timeline is as follows: 5.5 Governance 5.5.1 Following a Development Session with representation from both NHS Lanarkshire HSCP and North Lanarkshire Council, an initial Operational Group in Wishaw locality has been established to ensure the GIRFE principles are incorporated into current workstreams, with a Steering Group providing overarching guidance and governance for specific GIRFE work activity. The learning from this work will determine further work across the other 5 localities. 5.5.2 A Facilitation team has been established to lead and co-ordinate the GIRFE pathfinder project in North Lanarkshire, linking to all relevant programme and workstreams, and to engage with the national GIRFE learning network and design schools. 5.5.3 The GIRFE Framework is set out in Appendix A. 6. CONCLUSIONS 6.1 Health & Social Care North Lanarkshire is participating the national Getting it Right for Everyone (GIRFE) pathfinder programme. 6.2 The initial focus for GIRFE in North Lanarkshire is on older people and adults living with frailty, working with the Locality Planning Group to develop the
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7 approach in the Wishaw Locality. The learning from this work will inform further work across the other 5 localities. The Board will receive further updates on the implementation and impact of at a future meetings. 7. IMPLICATIONS 7.1 NATIONAL OUTCOMES Link(s) to National Health and Wellbeing Outcomes People are able to look after and improve their own health and wellbeing and live in good health for longer ☒ People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonable practicable, independently and at home or in a homely setting in their community ☒ People who use Health and Social Care Services have positive experiences of those services, and have dignity respected ☒ Health and Social Care Services are centred on helping to maintain or improve the quality of life of people who use those services ☒ Health and Social Care Services contribute to reducing health inequalities ☒ People who use Health and Social Care Services are safe from harm ☒ People who work in Health and Social Care Services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide ☒ Resources are used effectively and efficiently in the provision of Health and Social Care Services ☒ 7.2 ASSOCIATED MEASURE(S) Associated measures include: A&E attendances Unscheduled bed days Delayed discharges Emergency admissions Re-admissions Improved assessment/planning outcomes Co design evidence 7.3 FINANCIAL This paper has been reviewed by Finance:
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8 7.4 RISK ASSESSMENT/RISK MANAGEMENT Relevant Risk Register Details Current Risk Level Risk Owner Choose an item. 7.5 ENGAGEMENT & PARTICPATION Please tick the engagement and participation objectives that link(s) with this piece of work and provide further details regarding the engagement and participation that was undertaken. Objectives Further Details ☒ Involve stakeholders in the development work aimed at achieving the national outcomes ☒ Provide stakeholders with information on how to get involved ☒ Ensure a diverse range of engagement and participation and opportunities are in place to suit different needs ☒ Measure how well we involve community stakeholders in the planning, design and delivery of our services ☒ Provide regular feedback on how stakeholder engagement and participation is shaping and influencing service development and delivery ☒ Provide support to enable stakeholder representatives to participate meaningfully and confidently at meetings ☐ Develop participation guidelines to ensure a common understanding and set of expectations for both stakeholders and partnership staff ☒ Support engagement planning and participation in localities, taking account of other engagement activity and local plans across the Community Planning Partnership Yes ☐ No ☒ N/A ☐
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9 7.6 INEQUALITIES & FAIRER SCOTLAND DUTY EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: Yes ☐ No ☒ N/A ☐ EQIA added to website: Yes / Date added ☐ No ☒ N/A ☐ 8. BACKGROUND PAPERS None. 9. APPENDICES Appendix A: GIRFE Framework CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following: Trudi Marshall Trudi.Marshall@lanarkshire.scot.nhs.uk
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10 Direction from North Lanarkshire Integration Joint Board (IJB) 1 Reference Number 202311-12 2 Report Title GIRFE 3 Date direction issued by IJB 4 Date from which direction takes effect 5 Direction to: 6 Does this direction supersede, revise or revoke a previous direction – if yes, include reference number(s) 7 Functions covered by direction 8 Full text of direction 9 Budget allocated by Integration Joint Board to carry out direction 10 Performance Management / Governance arrangements 11 Date direction will be reviewed
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11 Appendix A: GIRFE Framework