In this section...

  1. How we make decisions
  2. Our priorities
  3. Policies and procedures
  4. What we spend and how we spend it
  5. Who we are and what we do
  6. Work for us
People at singing and signing event at Truro

Build services with our partners, around localities and neighbourhoods

Teams across our services will be aligned with our partners, to work across organisational boundaries in the care of a local population. To do this we will work to the collective aims of prevention, integrated working and sharing the outcomes we are trying to achieve. We will have a leading role in the secondary prevention of illness and relapse and will support our locality partners such as VCSE in primary prevention and addressing the social determinants of health.

There will be the opportunity to move toward sharing premises where we can and the use of the same IT systems as our partners. In doing this we can see all what care is being provided, what people have decided they really want from their care, and how we can achieve it together.

Population health data will tell us about the specific needs of each locality and services will be enabled to adapt to achieve equitable outcomes for people across Cornwall and the Isles of Scilly. Through joint training, mutual supervision, shared outcomes and collective support we will feel part of a team of teams in every area.

How we will do this

Work with our partners to build integrated neighbourhood teams

This will be enabled by aligning our digital systems, using our combined buildings to work from the same bases. Training, sharing the expertise we have and supervising and learning together to achieve common outcomes.

Use population health management to guide service design at neighbourhood level

This will have a clear focus on reaching the most disadvantaged in our communities.

Create a Prevention Framework with our partners

This framework and machine learning based risk stratification and segmentation tools will enable us to identify patients at integrated neighbourhood teams level who need intensive, proactive or continuity-based support. Engagement in programmes such as weight loss programmes, diabetes reversal, smoking cessation will be monitored in integrated neighbourhood teams, enabling a reduction in premature death from cardiac, respiratory disease and cancer in disadvantaged groups.

How will we know we have achieved this?

We will know we have achieved this when:

  • our teams are working as part of 16 integrated neighbourhood teams across Cornwall and the Isles of Scilly
  • a maturity matrix demonstrates the evolution and development of the integrated neighbourhood teams, including shared objectives, education, supervision and management as part of maturity
  • population health management is routinely used in the design and provision of care across the 16 integrated neighbourhood teams
  • we can demonstrate patient user engagement in prevention activities at an integrated neighbourhood team level

Linked Care Quality Commission statements

  • Safe systems, pathways and transitions.
  • Care provision.
  • Integration and continuity.
  • Equity of access.
  • Partnership and communities.