Live Well Service in Milton Keynes

Employment of a frequent user lead in Milton Keynes aims to deliver the following outcomes: • Effectively manage, coordinate and sign post High Intensity Users of the local ambulance service and A & E within the CCG footprint. • Reduce the activity High Intensity Users have on GP practices • Establish, utilise and coordinate multi-agency and existing professional services to negotiate an adequate reduction in 999 calls including connection with local communities, statutory and non-statutory agengies as required. • Co-ordinate the fortnightly HIU MDT Meetings • Demonstrate a reduced workload on unscheduled care services and the wider health economy resulting from reduced 999 calls, which otherwise would have attended A&E, result in an admission. • Safely manage and coordinate the chaotic and demanding nature of the patient group through the use of multi-agency support and the volunteer sector. • Provide fertile commissioning intelligence across all providers and in doing so, lower the stigma associated with High Intensity Users. • Coordinate a replicable service which can be integrated and managed over the longer term across other providers.

The objectives of the scheme are to:- Measurable: • Identify those at greatest risk of 999 calls, A&E attendance and non-elective admissions. • Proactively manage a rolling cohort of High Intensity Users using a truly personalised approach. • To coordinate, sign post and oversee other identified High Intensity Users • To coordinate the 2 weekly HIU MDT meetings • To provide training and support to other providers to ensure patients are empowered to take ownership of their health and well-being whilst decreasing their dependency upon unscheduled care services. • Reducing 999 calls • Reducing A&E attendances and avoidable emergency admissions More difficult to measure but essential: • Forming robust network of community health, social care, mental health and police to manage patients, creating true integrated working. • Providing a service driven by quality with positive human outcomes observed. • Act as a conduit to negotiate and de-escalate issues before a crisis occurs; a situation which has historically led to a destabilisation of their condition and resulting in a 999 call. • Improving communication and partnership working between those involved in patient care 24/7. • Assist other providers to identify patterns and 'causal factors' which trigger relapse behaviours in former High Intensity Users in order to shape future commissioning of service and/or demand/capacity planning • Empower patients to self-manage.to enable discharge and to switch them from negative to positive contributors of society. • Drive equality and patient voice.

Additional information: Expected Outcomes: The key outcomes that the proposed service will deliver are: • Impact positively on reducing the amount of High Intensity Users emerging to replace those already managed • To support patients to flourish through improved lifestyle and well-being; this may include preparation for employment for some people. • A new culture of health coaching as a medium to deliver sustainable change. It is recognised that the latter two points of expected outcomes are more difficult to measure but they are essential outcomes if a culture change is to occur to lower the stigma associated with this cohort.

This contract was awarded by utilising joint funds from the Department of Health (DH), that the Provider had sought. NHS Milton Keynes Clinical Commissioning Group (CCG) made the decision to part fund the contract via a Single Tender Waiver signed off by the CCGs governance process. The non-DH funding is provided by the CCG, Thames Valley Police and Milton Keynes University Hospital NHS Foundation Trust. This part of the funding has been agreed for year 1, but the split between stakeholders has not as of yet for year 2 and onward but the total amount will not change.

Funding for Year 1: DH derived = £207,000 CCG and other stakeholder funding = £99,000

Funding for Year 2: DH derived = £100,000 CCG and other stakeholder funding = £199,000

Funding for Year 3: DH derived = £40,260 CCG and other stakeholder funding= £260,040

The contract would not have been possible without the funding that the Provider sought from the DH.

This Contract Award notice is on behalf of NHS Milton Keynes CCG as the Commissioner responsible for the healthcare commissioning for the cohort of service users this service will see.