North Somerset Council: local authority assessment

The Health and Wellbeing Strategy was being re-written (led by public health on behalf of the local authority), with work underway to ensure greater representation of adult social care in the refreshed strategy, with closer alignment with the health and wellbeing board. The local authority recognised there was a need to reduce duplication of people needing to ‘tell their story’ more than once to health and social care organisations. There were projects, for example, the Frailty Assessment and Coordination of Urgent and Emergency Care service (F-ACE) to ensure that there was a social care wrap around offer to support clinical colleagues and services, which had supported this.

Senior leaders and partners told us that professional relationships were mostly good within North Somerset. The local authority valued the trust and support that came with collaborative working which was supporting innovation around the use of TEC and other services, exploring the future of artificial intelligence (AI) within assessment processes.

The local authority was working to implement actions from new strategies that had been developed by designating lead officers to implement, monitor and feedback regularly to the health and wellbeing board. A TEC strategy and action plan was beginning to evidence a digital switchover, digital transformation of services and support the development of a longer term outward looking strategy from 2026 onwards. However, it was too early to analyse any evidence and understand the strategic impact on people and partnership working.

North Somerset local authority was part of the Integrated Care System (ICS) ‘Healthier Together Partnership’. The work of the ICS was guided by the ICS strategy and a joined up forward plan 2024-2029. The ICS consisted of 10 partner organisations, including three local authorities, NHS Trusts, a new Integrated Care Board (ICB) and community providers, including primary care. The local authority worked within two Integrated Care Locality Partnerships – One Weston, sometimes called Weston, Worle and Villages, which covered the south of North Somerset. Another called Woodspring, which covered the north. The local authority had set out a shared local commitment with the two locality partnerships ‘Healthier Together by Working Together’ and a shared aim to ‘To promote wellbeing by helping people in North Somerset be as independent as possible’. Senior managers within the local authority were attendees within both boards and governance groups, and a service development manager was jointly commissioned and reported into both the locality partnership and the local authority to support effective partnership working and expand offers to community partnership working. For example, a ‘Dementia Community of Practice’ had recently been established by the service development manager and an Older Persons Clinical Lead in the Avon and Wiltshire Mental Health Partnership. The aim was to drive forward better ways of working across all organisations that support people living with dementia with a key focus around personalised care planning and training, this was in progress to be approved and provide a single approach to working with people living with dementia. The local authority was in the early stages of scoping a joint health and social care dementia strategy alongside a review of the wider dementia system pathways, to continue the work long term and support further partnership working.

The local authority had some pooled budgets and jointly funded services. For example, the local authority was the lead joint commissioner and brokerage service for health and social care in the area, this extended to a joint quality assurance service. Senior leaders told us the Better Care Fund had been effective in supporting hospital discharge arrangements. For example, A Dementia Wrap Around Care Team (DWACT) pilot took place between May 2023 - October 2023. The pilot was aimed at supporting people with a ‘home first approach’, opposed to transferring into a care home setting from hospital which could have an impact on people living with dementia independence. There was also joined up formal agreements around the arrangements for NHS Continuing Health Care (CHC) funding and for the funding of Mental Health Social Workers within the MINT team. The MINT (Integrated Mental Health Team) had been developed as a transformational change in community mental health services to address the local authority’s known ‘gap’ in delivery between primary and secondary care services. The local authority co-produced the model in North Somerset which had now been replicated across the 5 other localities in the South-West of England. MINT was a good example of how integrated working could benefit people with care and support needs. It was described as a ‘one-stop shop’ for people with mental health needs, with access to care from health, social care and the voluntary sector. The social care role had a focus on people’s wellbeing in line with Care Act duties to prevent care and support needs.

The local authority and its partners monitored the effectiveness of their partnership working and the impact this had on outcomes for people. Joint projects like the Multi-Agency Community Care Team (MACCT), showed the effectiveness of pooled resources, leading to a reduction in hospital admissions. Collaboration with health partners, such as the Integrated Care System (ICS), resulted in improved information sharing and more streamlined pathways for people and unpaid carers.

The (ICS) provided a framework for collaboration, with the local authority participating in locality partnerships, demonstrating a structured approach to integrated care. Including a Dementia Community of Practice, which exemplified collaborative efforts to improve care, although implementation of a single approach to dementia care planning was still underway. The pooled budgets and jointly funded services like the Dementia Wrap Around Care Team (DWACT) pilot showed collaborative resource allocation.

A strong example of effective partnership working was seen with the collaboration between partners in using data to identify communities where support would have the greatest impact. The local authority reported that this targeted approach had achieved positive results. By expanding the consistent use of data-driven approaches within adult social care, this supported understanding for addressing the specific needs of people and unpaid carers. Data was translated into meaningful insight, to prioritise resources and plan services effectively. This ensured there were preventative measures in place, promoting individual well-being and preventing needs from escalating, providing tailored support for people, to help them live as independently as possible.

A two-year transformation programme was in place, with initial financial targets being tracked and evidence showing they had been met. Demand modelling was used to establish the multi-disciplinary Transfer of Care Hubs (ToCH), but recruitment challenges had continued. Workforce modelling had also been completed to assess and justify the need for registered social workers, and this data had been used effectively. However, partners told us there were still ongoing challenges, particularly around staff shortages and the local authority’s decision not to implement a trusted assessor model, which could have expedited hospital discharge.

The integrated working model with Avon and Wiltshire Partnership (AWP) was one of the most significant collaborative arrangements for the local authority. This longstanding partnership embedded social care delivery into secondary mental health teams, creating a well-established, closely integrated model of working. The local authority was the only council in the Bristol, North Somerset, and South Gloucestershire (BNSSG) region to have a direct integrated model of working with AWP. This included a ward-facing social worker post, ensuring effective hospital discharge planning and continuity of care. The Wellness Solutions Service, which provided proactive mental health and well-being support and dedicated training routes for Approved Mental Health Professionals (AMHPs) development. This included the social workers crossing into therapeutic service delivery, enhancing multi-disciplinary practice.

Staff teams across the local authority also reported good collaboration, working well together to support each other and to promote the best outcomes for people. Staff told us working collaboratively across teams, worked well. All were working towards the same goal but each bringing their own expertise and strengths.

The local authority had carried out an engagement mapping exercise, which identified they worked with around 185 partners across 18 areas of practice interest including advocacy, dementia, older people, carers, disabilities, domestic violence and many other practice areas. This mapping exercise also highlighted some gaps in their engagement which they had been making progress on to close and establish good working relationships and connections to understand and meet local social care needs.

The local authority had long standing partnerships with national and local independent charities and valued engagement with voluntary organisations to improve community-level engagement and strengthen community voices. Larger organisations tended to be more involved strategically with the local authority, one national partner told us they are very involved in supporting opportunities and promoting the contribution of the voluntary sector. For example, they were part of the planning future dementia offers and service developments. They felt the local authority valued their contribution and looked to them as experts around dementia. Another partner told us the local authority recognised they couldn’t do it all on their own and actively pursued working with the voluntary and charity sector. This organisation stated that the local authority engaged well with them and other partners. Another large partner told us they had quarterly meetings in the past with the local authority, but these had lessened due to staffing changes. The organisation felt the working relationship with the local authority could be better and more productive and they could be involved earlier in some processes to allow greater benefit to the community. A smaller partner told us if they were not in attendance at meetings they would often get missed from the agenda. There was mixed feedback with some partner organisations saying there was more to be done to ensure voluntary and charity sector groups within the area had improved communication with the local authority.

Senior leaders told us the voluntary sector were strong partners, particularly through the work of a local infrastructure support link for the Voluntary, Community, Faith and Social Enterprise (VCFSE) in North Somerset. Staff told us they worked closely with mental health, police services and the housing team within adult social care and attended weekly meetings focused on high risks associated with people who were homeless to improve their safety and wellbeing. Staff told us they often referred people to a local independent charity to provide support around domestic abuse, people with disabilities and older adults. Staff also referred people to a mental health charity that supported people through suicide prevention support and a range of free in-person and online wellbeing activities, workshops and courses. There was mixed feedback from local voluntary and charity sector partners. There was a frustration amongst some partners that larger organisations were offered contracts and the funding from the local authority was often directed toward specific priority areas, such as housing associations which the smaller charities did not regard as VCFSE sector. Small charities are an integral part of communities. They often serve as expert support, a number for people to call for advice, and a welcome safety net during a crisis.