Hertfordshire and West Essex Integrated Care Strategy

Appendix 1: our approach to engagement in developing the strategy - 'Start with people'

Effective engagement empowers people to shape, understand and access the services and support that are available to help them to lead healthier, happier lives. The Health and Care Act 2022 mobilises partners within Integrated Care Systems to work together to improve physical and mental health outcomes, and places legal duties on organisations to ensure that their actions are informed by the needs, experiences and aspirations of the people and communities they serve.

In drawing up this strategy, we have used a variety of methods to learn from the people and communities in Hertfordshire and west Essex, observing the Health and Care Act’s requirement to use existing insight about the needs and experiences of those living and working in our area, and to work with the partner organisations that have close links to them.

Guidance on developing ICP strategies cites the following groups as those who face the biggest health inequalities, and who therefore should be engaged when drawing up the priorities of our strategy:

  • black and minority ethnic voices
  • children and young people
  • children and young people with special educational needs and disabilities
  • disabled people
  • inclusion health groups
  • LGBTQ+ people
  • maternity voices partnerships
  • members of the Armed forces and their families
  • older people
  • parent and carer panels
  • parents, carers and families (including new and expectant parents, and foster parents)
  • peer supporters and informal advocates
  • people in contact with the criminal justice system including offenders, and prisoners
  • people living in deprived areas
  • people who draw on care and support
  • people who draw on mental health services, (including children and young people)
  • people with a learning disability, autism and other neurodevelopmental disorders
  • people with lived experience of suicide and self-harm
  • religious and faith groups
  • transient populations
  • unpaid carers including people providing care at a distance, and young carers
  • women’s and men’s health and care groups.

Our approach has sought to make the most of the information available to our system through the wealth of engagement work which has taken place in recent years, seeking out the views and experiences of people of those (such as the groups listed above) who face the biggest challenges to living healthy lives. Our learning from this work has been strengthened through additional engagement activities commissioned in order to shape the priorities of this ten-year strategy.

In summary, we have:

 

Literature review

Rich feedback on public and voluntary sector services in Hertfordshire and west Essex, capturing people’s lived experiences, and their views and suggestions, is available through reports, surveys and feedback documents. These source studies vary widely in scale, methodology and scope – from qualitative studies of 12 young people living in a secure mental health unit, to quantitative, demographically representative studies of 1,000 Hertfordshire residents and 15,500 NHS employees from across our ICB area. We developed a template to enable us to summarise each report/survey/feedback document considered, pulling out key findings, recommendations and where possible, direct quotes from participants.

This work was then fed into and cross-referenced with our developing Integrated Care Strategy. As well as insight into specific areas, such as caring, addiction, or dementia, for example, some themes emerged, including loneliness and mental health concerns. The importance of, and access to timely, culturally sensitive and appropriate information and sources of support was revealed as a priority for many people.

Some of the studies reviewed include:

  • Addressing obesity in Stevenage, Hertfordshire: a consultation with young people, 2019
  • Community Development Action COVID-19 recovery survey, August 2021
  • Healthwatch Essex: Dementia Voices, 2017
  • Essex Health and Wellbeing Survey Report, 2022 to 2026
  • Healthwatch Essex: Sweet!3 - experiences of young people in secure mental health units, 2018 to 2019
  • Hertfordshire County Council Children and Young People’s Health and Wellbeing Survey, 2021
  • Hertfordshire Health and Wellbeing Survey Report, January to February 2022
  • Healthwatch Hertfordshire: Making local healthcare equal - Healthcare concerns in Black and Asian communities, September 2022
  • NHS staff survey, Autumn 2021
  • Healthwatch Essex: Addiction: gambling, drugs and alcohol, April 2022
  • Mental health self-care in Essex, 2016-2017
  • Healthwatch Essex: Young mental health ambassador discussions on body image, August 2022
  • Consultation on health and wellbeing services in Hertfordshire

A directory of the source studies drawn from (where these have been made publicly available) will be published online. They will form an ‘insight bank’ resource for service providers and commissioners from both the public and voluntary sector. They will be shared with the strategy development team to inform the ongoing development and delivery of the strategy.

 

Focus Groups

In order to ensure that the priorities of people who can struggle to make their voices heard through traditional engagement activities have been taken into account in developing this strategy, a specialist research organisation was commissioned to hold targeted focus groups.

Four separate groups were held, attended by public and voluntary sector representatives who work with and advocate for:

  1. people living with poverty
  2. inclusion health groups
  3. people from Black and Minority Ethnic backgrounds
  4. parents, children and young people.

Each group was asked:

  • What are the main issues and challenges that impact on the health and quality of life of the people you work with?
  • What are the measures that could be taken that would help?
  • How can organisations be more joined up to deliver the change being suggested?
  • What can your organisation do to support?
  • Are the developing priorities in our strategy the right priorities?
  • Is there anything else we should include?
 
Focus group feedback

Recommendations from participants working with people living with poverty

  • Need to be flexible and tailor actions and measures to neighbourhoods. 'Centralisation’ can be a problem.
  • People need to better understand the long-term impact of a poor diet and obesity. There is still lack of understanding.
  • Access to services can be difficult. There is a need to make this simple and sometimes ‘human’ rather than always online.
  • Replicate the good things that happened during the COVID-19 pandemic: consistent messaging; outreach activity; COVID marshals.
  • It is better to use trusted community members, not the council
  • All partners need to know what everyone else is doing. Things are still fragmented. There are some examples of where this works.
  • Make more use of social prescribers and not just in responsive way but in a more proactive way.
  • There is value in people taking more control themselves, rather than expecting or waiting for something
  • There is lots happening, but funding is a problem (including public health funding)
  • Businesses who want to help (as they did in the COVID-19 pandemic) and to give something to communities should be supported and matched to community.

Views on the draft strategy priorities from participants working with people living with poverty

  • The environment was seen as a key concern which has an impact on all our priorities – however there was some doubt as to whether environmental improvements could be delivered.
  • Prioritising children is important as there are long term benefits from this. There should be much more engagement with schools – make use of them as the centre of their communities.
  • Scepticism about delivery of strategy – requires so many partners and if it is just NHS delivering then won’t work as so much else that is important.
  • How are we going to measure the effectiveness of the strategy and whether its priorities are delivered?

 

Recommendations from participants working with ‘inclusion’ health groups

  • Problem that health professionals don’t live in same communities/understand the people they support. They can’t see that someone might need to choose between paying a bus fare to the foodbank or to the GP.
  • Relationship between GP practices and local people can become confrontational, and opportunities are missed to identify other issues where help could be provided.
  • Services need to signpost well – not rebuff. There is always a group who can help – even if just advice or a cup of tea.
  • People get used to certain services – GPs and hospitals – and the shift to others can be difficult.
  • Services work in an isolated way and have their own priorities, rather than everyone looking at the community or situation as a whole. They don’t see how what they do (e.g. planning department) has an impact on health, for example.
  • More joined-up working has started but needs much more co-ordination. Sharing workspace could help.
  • Make better use of social prescribers.
  • Resources in voluntary sector is a problem as the number of volunteers has dropped since height of COVID-19 pandemic. There are fewer volunteers to support.

Views on the draft strategy priorities from participants working with ‘inclusion’ health groups

  • Priorities need to be more precisely and simply worded so people can understand.
  • Targeting to help reduce inequalities is good and it happens; need to be careful that this doesn’t come at the expense of wider improvements in healthcare.
  • Priorities feel just like normal business – what we should be doing anyway.
  • Carers should feature more prominently in the strategy – family carers.
  • Women should feature more prominently in the strategy. 

 

Recommendations from participants working with people from Black, Asian and Minority Ethnic Groups

  • The impact of the cost of living is huge – 70% of calls to Herts Help advice line concerning cost of living.
  • The accessibility of services to South Asian communities is important - language barriers and the cultural sensitivity and understanding of staff on the front lines of the services.
  • Lack of trust in authorities and health and wellbeing services because of overt racism. Several examples were given.
  • Lack of trust in police amongst these communities – trust damage by ‘stop and search’ policies.
  • Lack of continuity of care (mental health services).
  • Cultural insensitivity – for example, mental health counsellors who do not understand or try to challenge people’s religious beliefs.
  • Challenges Voluntary, Community, Faith and Social Enterprise (VCFSE) sector face because of the increase in pressure on their services. One of the participants runs a charity but also is also runs a shop and works full time. Their business gets busy towards Christmas – just as there is increased demand and pressure on the VCFSE sector.
  • Funding goes to established VCFSE organisations for outreach into communities that these organisations have limited experience with – this comes at the expense of smaller organisations that have better links but are less well known.
  • Participants wanted to see a greater emphasis on supporting grassroots organisations to support people from South Asian communities.
  • Having places of worship was seen as an important way in which issues of mental health could be addressed. Places of worship could also be places where authorities reach out to these communities. Difficulties with securing planning permission to build a temple in Watford.
  • Participants discussed the need for people within these communities to have decision making power, rather than to simply be consulted.

Views on the draft strategy priorities from participants working with people from Black, Asian and Minority Ethnic Groups

  • Participants were generally supportive of the priorities and their comments were related to checking that specific groups were included in these priorities – for instance carers. There was a particular concern for young carers from South Asian communities who are often involved in care and support for adult relatives because they are often more fluent in English and better placed to navigate systems in the UK. 

 

Recommendations from participants working with parents, children and young people

  • Mental health problems and lack of access to services was mentioned by most in the group as being the biggest issue affecting the wellbeing of young people.
  • Teachers are struggling to cope with issues their students present with due to lack of time, training or awareness of what support is most appropriate.
  • An increasing issue at present is young people who are struggling with their gender identity, particularly common among those with autism.
  • Social prescribing is an important way of supporting young people.
  • A Scottish initiative which is training all teachers in nurture-based practice is seen to be working very well and reducing exclusions from school.
  • Having spaces where young people can speak to adults who are separate from family and friends is beneficial.
  • We need to link up our community organisations and their activities.
  • Tackling cross border issues and infrastructure barriers is important.
  • We need to have agreed targets and outcomes and long-term funding in place.
  • Support for teachers, parents and others in contact with vulnerable young people is key. 

Views on the draft priorities from participants working with children and young people.

  • A number of the issues linked to the priorities could be closely related to adverse childhood experiences. Preventative measures could mitigate against these.
  • The workforce priority is critical across the NHS and other partners.
  • Funding that is on short-term cycles is deemed a problem that could mitigate the ability to deliver some long-term priorities.
  • Some felt there were too many priorities, how will they all be delivered?
  • How would priorities be monitored?
  • Reducing health inequalities was seen as underlying all the other nine and the group was not sure whether this needs to be a priority, or a general principle.
Responding to the focus group findings

The insights obtained as a direct result of these focus groups have helped shape our strategy. For example, although there was generally positive feedback about the 10 priorities that participants reviewed, there was concern there could be too many, and that they would not therefore be achievable. The number of priorities has since been reduced.

It was also noted that the priorities need to be expressed in clear language that can be understood by everyone. This has been taken on board by the strategy development team. Some themes, such as the importance of early help, the need for services to be ‘joined up’, the need for effective signposting of services and better awareness of services will need to run throughout the delivery of every priority.

The importance of identifying ways and means of evidencing actions that lead to the delivery of the strategy’s priorities was highlighted. This is an area where ongoing public and staff engagement and involvement will be vital in order to maintain confidence in the strategy and the organisations which have developed and own it.

The detailed insight gathered will contribute to the development of the Joint Forward Plan, which will be our system’s delivery plan for the integrated care strategy.

 

Surveying the ICP workforce and voluntary sector

An anonymous survey seeking the views of staff and volunteers working for Integrated Care Partnership organisations was distributed across our system, with the support of system partners. More than 750 responses were received over a two-week period. Respondents were largely drawn from the NHS and local government (both district and county councils), with the voluntary, community, faith and social enterprise sector and other public services, including the police service, also represented. 66% of respondents reported having some contact with, or offering support to, service users, patients, or members of the public.

The survey offered respondents the opportunity to give their views on some or all of -he 10 draft priorities they were presented with, both in terms of the personal potential impact of those priorities on themselves and their families, and the wider potential impact on their communities and the people they serve through their work.

The majority of respondents (59%) chose to comment on workforce as a priority, selecting ‘Recruit, develop and retain the people we need to provide health and care services for our population, ensuring that we have enough people with the right skills to deliver the best possible services’. This suggests that as the survey was taken primarily by people living and working in Hertfordshire and West Essex, respondents were interested in the priority most relevant to their career and progression.

Just under half of respondents chose to comment on a priority relating to mental and emotional health (48%) and a priority which focused on measures to ensure people maintain a healthy weight (47%). A priority which focused on addiction and its impact on health and wellbeing, had the fewest responses (24%), although of those 24%, more than half said that this priority would have an impact on them as individuals, and two thirds said this would impact their family or friends.

When asked in an open question whether they wanted to comment on the strategy priorities overall, 180 respondents raised the following issues:

  • Generally positive sentiments (41%)
  • Needs adequate staff/skills processes to be delivered (14%)
  • Needs detail on delivery, monitoring and evaluation (12%)
  • Needs adequate funding to be delivered (11%)
  • Improved partnership working needed for this to work (9%)
  • Co-production is needed or would be useful (7%)
  • People need to be enabled to take ownership of their own health/have access to right information and services (6%)
  • Focus on those most in need or do a small set of things well rather than too many not very well (2%)

When completed, the detailed survey report will be made available to the strategy team and the public and published alongside this strategy. 

 

System Wide Meetings

As part of our engagement plan in developing this strategy we have attended over 30 meetings with senior leaders to present the draft strategy and obtain feedback. This engagement has been crucial in ensuring that our strategy meets the needs of all our partners.

  • Hertfordshire and west Essex Integrated Care Partnership
  • Hertfordshire and west Essex Integrated Care Partnership Committee
  • Hertfordshire Mental Health, Learning Disabilities and Autism Collaborative Board
  • Hertfordshire and west Essex Integrated Care System Health Inequalities Strategic Board
  • Hertfordshire and west Essex ICS Programme Management Office Team
  • Hertfordshire and west Essex Integrated Care Board meeting
  • Hertfordshire and west Essex ICB  Design and Delivery Board
  • Hertfordshire and west Essex ICB  Primary Care Senior Management Team 
  • East and North Hertfordshire Health Care Partnership Board
  • South and West Hertfordshire Health Care Partnership Board
  • West Essex Health and Care Partnership Board
  • Hertfordshire County Council Children's Services Core Board 
  • Hertfordshire County Council Adult Care Services Senior Management Board
  • Hertfordshire County Council Public Health Management Board
  • Hertfordshire County Council Cabinet Members Panel 
  • Hertfordshire County Council Scrutiny Committee
  • Hertfordshire Health and Wellbeing Board
  • Hertfordshire District and Borough Council Chief Executive Officer Group 
  • Healthwatch Hertfordshire Community Assembly
  • Essex Children’s Board
  • Essex Partners Board (Essex County Council)
  • Essex County Council Health Overview and Scrutiny Committee 
  • Essex County Council Health and Wellbeing Board 
  • Healthwatch Essex Community Assembly 

 

Conclusion

Engagement and involvement should be an active, ongoing process, which provides clear feedback about the way in which involvement has led to improvements. We are committed to fully involving people and communities across Hertfordshire and west Essex as the strategy is further developed and delivered. Updates will be posted to the ICP pages of the Hertfordshire and West Essex Integrated Care System website and through a wide range of communications channels. Those directly involved will be kept informed so that they can see the impact that their views have made.