COVID- 19 good practice case study: Gateshead’s collective leadership approach

Gateshead Health and Care System comprises local organisations, including the voluntary and community sector (VCS), working together with an integrated approach to planning, commissioning and delivering health and social care. Its place focus is underpinned by a Memorandum of Understanding which enables it to focus on delivering Gateshead’s joint vision and its ‘Thrive’ agenda.

Services are delivered by Gateshead Care Partnership; this brings together five of these organisations: Community Based Care (CBC) which includes the Gateshead GP Federation, Gateshead NHS Foundation Trust, Gateshead Council, Cumbria, Northumberland, Tyne & Wear NHS Trust and Newcastle-upon Tyne Hospitals Trust. The Partnership won the HSJ Award 2018 for ‘Improved Partnerships between Health and Local Government’.

The system was already working to keep residents well and avoid hospital admissions; for example its work as ‘Enhancing the health of care homes’ vanguard and its ‘Falls car’.

Gateshead’s collective leadership ethos has freed staff across the system to be flexible and responsive to local circumstances; for example: 

• Redeployed community nurses provided a bridging service between GPs and Care Homes. When the community nursing workforce was 38 per cent down Allied Health Professionals backfilled their roles, for example, podiatrists provided footcare usually provided by district nurses.
• With Continuing Health Care (CHC) and funding eligibility assessments paused, clinical commissioning group (CCG) CHC nurse assessors moved into the community to help mobilise the D2A pathway and assess what support (if any) was required – bedded/ home based rehab/ reablement etc. 
• Community health care assistants have been deployed to support care homes with staff shortages, or work in domiciliary care to prevent admissions. 
• Cumbria, Northumberland Tyne & Wear NHS FT (CNTW) developed a staff wellbeing checklist which included how to function together Council staff have been redeployed into adult social care; there is now a small quality group of redeployees which gives capacity and contingency if there is second wave or peak.

Clinical associate role

The council has introduced a new clinical associate role that provides medical students with opportunities to gain hands-on experience working with care home residents – taking blood pressures, taking bloods as well as being part of virtual ward rounds.

A supervision matrix model has been developed that ensures the students get day to day supervision from the onsite manager, a fortnightly call with the council’s service director and the support of a mentor from a GP trainee.

Endorsed by Health Education England this role provides an interface between the onsite care team and GP practices as well as helping to provide timely swabbing in care homes.

NHS 111

As well as being deployed into inpatient settings, mental health staff volunteered to work in the NHS 111 call centre to provide extra support for those with mental health concerns. During their shifts they took the opportunity to network in a way that they hadn’t been able to before and enabled a wider multi-agency understanding of the system.

Community hubs were established across the borough and reached around 4,200 households.

Free food was needed by around 50 per cent of these households, routine shopping by 22 per cent, help with utilities by 8 per cent, help getting prescriptions was needed by 8 per cent and 4 per cent needed befriending/reassurance.

A crisis contact line was available 24/7. Everyone on the mental health waiting list was contacted at least once every four weeks and had access to a duty social worker or the crisis line should their condition deteriorate.

In response to concerns about visits to A&E dropping, the GP Federation relocated some GPs to offer walk-in clinics to encourage people to still seek clinical support.

Deployed staff made welfare and wellbeing calls to those shielding to help pick up any health, social care and safeguarding issues. Additional B&B accommodation was secured in a local hotel which was block booked to provide 36 rooms over lockdown for rough sleepers. By 3 April 2020, 92 households were supported in temporary accommodation across Gateshead. New homeless applications continue to be received and by the end of July 180 households had been rehoused into permanent council accommodation. Bluestone Consortium and Connected Voice brought a third sector perspective to the resilience meetings. Local charities were appreciative of the support and the interest shown in how they were coping and the issues they were seeing.

Healthwatch Gateshead reassessed its priorities to help towards improving local services from lessons learnt. By encouraging and sharing feedback from people using health and social care services, it reported to the Health and Wellbeing Board that: “Currently the trends coming out appear to be that people and services seem to have adapted well to the changes that have been made due to the pandemic. Some queries have been raised on Patient Transport Services and its criteria which we are following up for clarification. Other enquiries have highlighted people’s concerns about limited access to dentists and opticians.”

A&E response

Recognising the stress that a visit to A&E can cause for people experiencing mental ill-health, the Queen Elizabeth Gateshead Hospital repurposed three outpatients rooms to provide safe spaces for those experiencing a crisis. These rooms are used to provide much quicker and tailored response away from people attending with physical concerns.

Understanding lockdown

As part of the Keeping People Connected project, the Cumbria, Northumberland Tyne & Wear NHS Foundation Trust’s Learning Disabilities Team helped the people understand what lockdown was and what it meant by creating an upbeat video that also encouraged kindness and positive thinking.

We had already been working closely together so it wasn’t like picking up the phone for the first time.”

Gateshead Care Partnership mobilised quickly to establish how it was going to work as the pandemic developed:

• Gateshead's GP Federation has led the way in repurposing urgent care services to establish this vital COVID management infrastructure, with the support of Community Services Transformation Team and CBC Health’s Urgent Primary Care Team.
• GPs, health care assistants and administrators from general practice, community services, children’s services and CBC Health came together to deliver safe and timely assessment and treatment of COVID positive patients. 
• Home-visiting GPs have provided a service assessing COVID-symptomatic patients in their own homes/care homes if they are unable to travel to access essential care, supported by the Community Services Rapid Response Team and North East Ambulance Service’s GatDoc drivers.
• The sites for COVID positive patients, ‘hot sites’ have been supported by colleagues from community services providing operational management and colleagues from children’s services providing health care assistants.
• Facilities teams have supported the cause by managing patient flows in and out of premises and by maintaining high standards of building cleanliness and infection control. There was a joint effort with Gateshead Council supporting the establishment of testing arrangements by sourcing barriers for the testing car park.
• CCG colleagues have provided essential project support and secured an essential flow of PPE supplies to staff and clinicians working on the frontline.

The Gateshead system worked to ensure patients’ experienced safe, appropriate and timely discharges from hospital.

• The hospital discharge process was redesigned using a trusted assessor model and the discharge team extended its hours.
• A hospital health and social work team acted as a single point of contact for hospital professionals to refer into when a person is ready for discharge Gateshead Council contributed to facilitating timely discharges by:
• its placements team operating seven days a week
• expanding and maximising the workforce capacity by incorporating the CCG contracts for domiciliary care and hospice into their offer
• agreeing a fair financial offer for care providers, backed up by commitment to independent audit
• block booking residential beds with specialist nursing and end of life care to ensure smooth transition of patients within the three hour window
• Commissioning a bridging service from the independent sector with staff paid whether or not they worked to provide a short term service until a suitable domiciliary care provider had capacity
• CBC Health’s community team made welfare calls to people discharged on pathways.

A whole system approach was taken to supporting residents in care homes:

Establishing emergency planning arrangements enabled partners to provide a coordinated response and ensure that timely support and training was available to care homes.

Community Nurse Practitioners visited or made contact daily with 24 older persons care homes in Gateshead to give advice on care, train staff, update end of life documents and care plans or swabbing/COVID testing residents. Recognising the vulnerability of care homes, local lab capacity at the Gateshead NHS Foundation Trust was used to provide testing for care homes.

The GP leadership in the Partnership provided advice and support to GPs in implementing the Enhanced Health Care in Care Homes mandate.

The Specialist Palliative Care Nurses in the community contacted every care home to give advice and to offer support to the staff caring for residents nearing the end of their lives. 

Community Nursing Teams were able to continue to provide palliative care to support patients at the end of their life. They had the back up of guidelines, developed by a Macmillan pharmacist, for the delivery of end of life medications by carers that could be implemented should the need arise. 

New 24/7 hotlines have been set up to provide further expert support provided by a range of specialisms: elderly care physicians, palliative care consultants and the end of life team, the MacMillan nurse.

A Care Home Multi-Disciplinary Team was led by community geriatricians.

PPE and donations of toiletries were shared across a number of homes. Ipads were suppled to care homes to allow virtual consultations. 

A 5 per cent top up on residential fees was paid to accommodate extra expenditure as well as a financial package which allows homes to claim additional expenditure above and beyond through a transparent ‘open book’ approach.

The system has engaged Collective Impact Agency to facilitate discussions about what’s enabled it to respond and to consider how it can embed this learning for the future.

Ideas are evolving about how the system wants to build its resilience; for example: promoting ‘talk before you walk’ to reduce footfall in primary care, how to sustain GPs role in triaging NHS111 calls, acute AHP staff following patients out of hospital, conversations with care home providers where they identify sustainability issues due to reduced occupancy to agree support to ensure future sustainability and involving them more in Gateshead’s transformation plans.

The learning from the community hubs is being used to develop a phase 2 to be operational from September that will be person centred, locality based and multi-disciplinary.

Gateshead Council and The Gateshead Housing Company are working in partnership with the MHCLG’s Next Steps Accommodation Programme to determine plans for Gateshead and their commitment to end rough sleeping.

• “Gold command enabled the tight flow of information from floor to top execs. What really made a big difference was services being empowered and trusted to make the right decisions for their client group. The services know their client group – they had the power and autonomy. These examples and initiatives were bottom-up.” 
• “this brought people together and we are now exploring how to do more of this going forward”
• this single issue focus means you can make progress really quickly but how can you sustain that with competing agendas?”
• “What worked well was having a shared common goal and increased trust between staff. System that beyond organisational boundaries.”
• “We have a real opportunity to solidify and build on the good work we’ve done.”