The Oldham Model

Source: NHE May/Jun 2019

Dr Carolyn Wilkins OBE, accountable officer of NHS Oldham CCG and chief executive of Oldham Council, provides an overview of the health and social care integration work taking place in the borough.

Under the Oldham Cares banner our alliance of partners has a shared goal: “To see the greatest and fastest possible improvement in the health and wellbeing of the borough’s residents by 2020.” This ambitious goal has meant we’ve had to work differently to revolutionise and innovate in our approach to integrating health and social care services.

Oldham is a co-operative borough. It’s a place with a strong history of working together and one where everyone is encouraged to do their bit towards creating a confident and prosperous town to live and work.

Quality of life in many areas is good, but there are also unacceptable levels of deprivation and poor levels of health and wellbeing affecting many households. Our commitment is to helping people find and keep good health for longer, and achieving a better overall quality of life.

Oldham Cares is a one-system approach that brings together Oldham Council, NHS Oldham CCG, general practitioners and other health and social care providers in an alliance to share our skills, experience, talent and resources to deliver a better care experience. Also working alongside us are other important wider partners such as police, the fire service, housing providers and local businesses.

Together, we’re striving to put the essentials for a good quality of life in place, like housing, employment, education, transport and environment. The prize is to achieve that significant improvement in residents’ health and wellbeing and reap the huge long-term benefits that lifestyle changes bring – and we know we can only achieve that change working together, especially as budgets fall and demand increases for all our services. 

Our Thriving Communities programme takes an asset-based approach and seeks to build on the strengths, people and groups that already enrich our neighbourhoods to take a stronger approach to earlier intervention and prevention. By using community resources, we can tackle problems earlier rather than dealing with costlier outcomes later. Crucially we can empower residents to take control of their health, wellbeing and social welfare, by ensuring they can easily access the right help, at the right time and in the right place.

In its Long-Term Plan, the NHS announced an intention to increase the prescribing of social activities to patients, which is already embedded in Oldham. With nearly 10% of our residents self-identifying as lonely, we’ve made a real commitment to tackling this through our community led-approach.

By connecting people to local groups, facilities and activities like walking, talking, gardening and other social support, we can improve health and wellbeing far better than by simply providing medication alone. 

In March this year, we marked the world’s first Social Prescribing Day by awarding a pioneering three-year contract to a local consortium of voluntary and community organisations. This created a Social Prescribing Innovation Partnership arrangement which is thought to be one of the first for the public sector in England.

This new partnership works alongside Oldham Cares Alliance partners and the Voluntary, Community, Faith and Social Enterprise (VCFSE) sector to further co-design, establish and deliver our social prescribing.

What’s fundamentally different about this approach is that it gives our local consortium the flexibility to work with partners and residents to design and iterate a service that meets local needs. This is rather than a service being designed and ‘fixed’ at the outset, as we know modern commissioning needs the agility and flexibility to respond. 

Also, this not only focuses on linking people into community groups to meet the ‘more than medical’ need – but it puts community development at the heart of the model. We need to better support these groups more in the future if we truly want them to do more to support our residents earlier in the care pathway, and stop their health needs escalating when it could have been different.

The Social Prescribing Innovation Partnership is just one part of our goal in whole system transformation – but the principles apply across the board for Oldham Cares. These are ‘be person focused, co-design and be ambitious and innovative to affect change.’

Rani came to Oldham from India three years ago and is recently widowed with a one-year-old daughter. Her GP referred her for social prescribing due to mild depression. She contacted Action Together – the organisation running Social Prescribing in Oldham – and was linked up to a knitting group at her local community centre. Her connector found a play and stay session for her daughter, and Rani went on to start further education with Oldham Lifelong Learning Service and is now looking for employment.

Rani said: “The Social Prescribing service is excellent - five stars. I am really happy and I have enjoyed going to the sewing classes and MIND. I feel like they will really help me. I feel like someone is looking out for me. I will be continuing to attend the activities.”

Co-design and integration are now the maxim across all our health and social care as we develop our cluster model further. Working in a place context we have also developed community-led services joining professionals and social workers, district nurses, health care assistants and representatives from the Social Prescribing Innovation Partnership into integrated multidisciplinary teams (IMDTs). These work from the same building sharing knowledge and resources to improve outcomes for residents.

Our Focused Care teams are a key part of integrated working. Based in GP surgeries, they focus on the people who need care the most to improve their lives and reduce pressure on the wider NHS.

Focused care is about identifying social, financial, educational or other factors within households where medication alone will not fix a problem. They take patients from chaotic households and work to gradually unpick their difficulties step by step.

Social prescribing and focussed care are complimentary models working side by side in Oldham.  Social prescribing focuses on building that critical community capacity and being the glue, which joins people into that grassroots ‘more than medical support.’ Focussed care has the ability to work with individuals and families with more complex needs.

Dr John Patterson, chief clinical officer for the CCG and a key leader across the Oldham Cares Alliance, said: “There are so many people who think they don’t deserve their mental health to be fixed, or they don’t deserve to be happy. All these clichés are actually true and we see it again and again, especially when people are overwhelmed by poverty and complexity. This is a project to focus the care of the system onto our most vulnerable households. By giving these vulnerable families access to good NHS and good general practice care; they reduce their A&E use by up to 40%.”

The Oldham Model is making a real difference. This has three interdependent goals. Firstly, we are working to build Thriving Communities that are resilient with strong assets, people and groups who are supported to improve. We do that through our Co-operative Services, which focus on delivering social value. This in turn is helping us to work towards an Inclusive Economy where everyone can play their part in helping local people and businesses prosper from introducing a Living Wage to delivering better skills prospects, investment and job opportunities.


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