We supported the development of a new Health and Wellbeing Hub in Shrewsbury by designing and agreeing on integrated care models based on best practices for frailty, long-term conditions, peri-operative care and discharge. We delivered new fully integrated service models for the four pathways and drafted future service profiles, informed by public and provider stakeholder engagement.

Background

NHS Shropshire, Telford and Wrekin ICB were looking to inform the future service profile of a new Health and Wellbeing Hub in Shrewsbury. Strategic planning had been stalled by the COVID pandemic, and a different approach was needed to ensure service transformation would incorporate and build on the changes made during COVID.​

Action

We used a combination of data sources, including demographics, local data and national data sets to develop demand and capacity models  across four pathways:​

– Frailty​
– Long-term conditions​
– Peri-operative care ​
– Discharge.​

We explored best practice models and discussed these with providers in a series of workshops. The ICB engaged with the public at the same time.​ Demographic analysis and extensive engagement with providers led to the prioritisation of the frailty pathway for transformation since Shrewsbury has one of the highest percentages and fastest-growing elderly populations in the country. Alongside frailty, we looked at long-term conditions, peri-operative care and discharge as complimentary to frailty. They all required the same integrated multi-disciplinary team approach that the engagement work aspired to. ​
In addition, high-level financial profiles were developed for the pathways based on indicative workforce modelling. ​

Delivery by NHS Midlands and Lancashire

• Demographic analysis indicating population trends and likely impact on health service capacity.

• Presentation of best practice evidence base for frailty, long-term conditions management and peri-operative care.​

• Extensive engagement and workshops with all providers (multi-disciplinary and multi-organisational). Maintained a link with the public facing engagement exercises being run in parallel.

• Contributed to public focus groups and developed and delivered workshops for frailty, discharge and children and young peoples services (a further area for exploration that came up through the engagement work).​

• Development of demand and capacity models for frailty, long-term conditions, peri-operative care and discharge.​

• Indicative workforce forecast for new models of care​
  Financial modelling (high-level)​

• Led the multi-organisational Service Integration Group who were responsible for sign-off of pathways and business case inputs from a system service perspective.

• Drafted the ‘Future Service Profile’ section of the outline business case incorporating primary care inputs for GP practices and the primary care network alongside the proposed service transformation.

Impact

We successfully delivered a high-level future service model with pathways and demand modelling informed by public and provider stakeholder engagement. We supported the development of a new health and wellbeing hub in Shrewsbury by designing and agreeing on integrated care models based on best practices for frailty, long-term conditions, peri-operative care and discharge.​

In addition, we delivered new fully integrated service models for the four pathways. Future service profiles were agreed upon and drafted for the outline business case for the Shrewsbury Health and Wellbeing Hub.​ Providers were successfully engaged in the design of the new models of care via interviews and workshops. ​

Customer Feedback

CSU colleagues successfully delivered a high-level future service model with pathways and demand modelling informed by public and provider stakeholder engagement. NHS Midlands and Lancashire were excellent to work with and very organised and structured in their approach.
Emma Pyrah | Associate Director of Primary Care, NHS Shropshire, Telford and Wrekin ICB