The Integrated Care Across Northamptonshire (iCAN) Programme is now gathering pace and momentum as it moves into the first year of its Five Year Roadmap.

In the face of continued health and care system pressures caused by COVID and the roll-out of the vaccination programme, health, social care and voluntary sector colleagues are coming together to shape the work of each of iCAN’s three key workstreams (‘pillars’), their constituent projects (‘bricks’) and foundation governance structures.

During February, approval was given by system leaders to test the market for additional external support for the iCAN programme.  The procurement process is nearly concluded and it is anticipated that a way forward can be agreed with an appropriate supplier to support the next phase of the programme.

Since the last edition of Partnership Update, the three iCAN pillars – Community Resilience, Frailty Escalation and Front Door, and Flow and Grip – have been making strong progress to agree the aims, objectives, project group membership and key performance indicators of their constituent bricks.

All have initiated a number of projects which will start to deliver results in the coming months, and some examples of these projects are detailed in the panel below.

The schedule of iCAN Masterclasses has continued, with further sessions planned until early summer.  Dr Jyothi Nippani from NHS Improvement spoke about the frailty services transformation work that has taken place in Warwickshire and the significant patient and system benefits that this has realised. These have included the avoidance of hospital admissions where the right treatment and care for patients can be provided in the community, reduced lengths of hospital stay for those who do need to be admitted, and improved patient experiences.

More recently, there was a demonstration of a comprehensive clinical tool enabling health and care professionals across Northamptonshire to maintain a consistent approach to assessing people with frailty and recording frailty assessments. The Ardens Frailty Assessment template will be rolled out across the county soon, and this masterclass can be viewed online by clicking here.

iCAN projects: examples of activity

Frailty training programme

A new training programme for clinicians in Northamptonshire to support better care for people with frailty is being developed in conjunction with the University of Northampton. Initially, this will begin with a Tier 3 level training module, with the first cohort of 25 places commencing in June 2021. Two further cohorts are planned for the autumn and early 2022, each with a further 25 places.

Acute hospital frailty hub

An eight-week frailty hub pilot project began on 1 March at Kettering General Hospital and Northampton General Hospital, in close collaboration with East Midlands Ambulance Service (EMAS).  The new initiative enables ambulance crews to telephone a single number (through the Consultant Connect service) which directs them to specialist frailty teams for advice on the most appropriate point of care for frail patients. This ensures the patient can receive the treatment they need in the right place at the right time, providing a better patient experience. During the pilot phase, access to a clinician within the frailty team will be available Monday to Friday between 9am and 5pm.

County-wide befriending service

The voluntary sector is taking the lead in the creation of the system of befriending vulnerable people, which is known to be of vital importance to provide opportunities for people’s social interaction and them feeling part of a community.  A county-wide service lead, supported by a co-ordinator in each locality, will work to build the network of volunteers and link to multi-disciplinary welfare teams in order to facilitate this work.

Primary care frailty services

As part of their work to develop services for people with frailty, several of Northamptonshire’s Primary Care Networks have identified Frailty Leads and are ready to move forward with Frailty Clinics for their areas. Implementation for each to go live will be driven by approval of a business case for implementation in 2021/22.

Improving in-hospital patient experience

Three distinct projects have been established to focus on improving the experiences of patients who are admitted to acute hospitals, to ensure that they are supported to safely return home or to their usual place of residence without spending more time than they need to on a hospital ward. One of these projects is looking at understanding and addressing the reasons why some patients remain in hospital beds for longer than they need to; another is working to ensure consistent standards in the diagnostics and tests patients receive in the lead-up to their discharge; and the third is developing agreed processes supporting frail patients to maintain their functional abilities during a hospital stay.