The vision is to place the individual at the centre of their care and support, ensuring their voice is heard and helping them to co-ordinate the outcomes they want to achieve. TAP was established to focus all services involved with an individual on the person and their needs, bringing everyone together to work on uncovering the root causes of issues, removing duplication in services.
How was the Team Around the Person service established in Sheffield?
TAP was codesigned with individuals with lived experience and colleagues from Adult Social Care, Housing, and Communities departments, GPs, District Nurses, therapists, Ambulance service, Police, Fire, community organisations and charities.
The sessions asked, “How do we work better together and improve outcomes” there was a clear message from professionals, based on previous experiences, that integrated approaches focused on service outcomes and Key Performance Indicators that did not fully involve the individual.
Through the codesign, the following principles of the service were agreed:
- To ensure that individuals are at the centre throughout their involvement.
- To ensure that individuals can identify the significant individuals in their life and form strong support networks fostering future resilience.
- To use a strength-based approach to communicating with and engaging with individuals/families, listening to their stories and supporting solutions.
- To coordinate the provision of multi-agency support that is accessible and meets the needs of individuals/families.
- To be ‘service-centred’ – understanding the aims of services/organisations and the barriers they face.
- To use evidence-based approaches and evaluation measures to ensure the best possible outcomes for individuals and families.
- To support individuals in implementing and reviewing their joint action plans to ensure they are relevant and tailored to their needs.
TAP was piloted in the Southeast of the city in 2020 and in 2023 has become available across the whole city.
The process
The TAP team are impartial facilitators called TAP Coordinators. The coordinators are a single point of entry, gathering information related to an individual case from multiple platforms across the health and social care system. These services and the individual are brought together, to create a joint action plan. TAP will help overcome personal and professional barriers and work within the commissioning framework to identify gaps in provision and service design.
TAP coordinates and facilitates these multi service meetings, allocates tasks, and maintains the momentum of support until the plan is completed and the individuals aims and objectives are met. Throughout the TAP, the Coordinator ensures there are regular updates and tasks are completed, and will request services to participate, or ask professionals to step away if similar agencies are involved. The TAP Coordinator ensures the person is kept at the heart, is heard and supported throughout the process.
Achievements
TAP delivers the quadruple aim of enhancing patient experience, improving population health, reducing costs and improving the work life of frontline workers. Developing a network within the city, has meant that services are coordinated, providing clear communication channels to deliver outcomes of benefit for the individual. Not only has this proven to increase patient safety through the reduction of risk, but it has also led to safer, more holistic practice amongst the workforce.
Analysis of qualitative feedback over the past two years has identified the following outcomes:
- Enhanced and improved outcomes for individuals and their families through a range of joined-up services, advice and support that is readily available and accessible.
- Building quality relationships between the health and care system, multi-agency front-line practitioners supporting integrated working locally. This approach helps to build consensus, strengthen partnership voice, and break down professional boundaries.
- Creating a more accurate assessment of risk and need, as decisions are based on coordinated, sufficient, accurate and timely intelligence centred around the individual.
- TAP helps to build a more cohesive community approach through multi-agency practitioners taking greater ownership and responsibility for addressing individuals needs jointly, therefore avoiding duplication or overlap of provision.
- Fiscal and cost avoidance savings across the health & social care system.
Reflections
TAP was established with little funding or resources and instead aimed to re-purpose existing financing to meet the needs of the individual. The project was initially small and localised, which worked well during the test and learn phase; however, TAPs success drove demand which quickly outstripped capacity. Word of TAPs positive approach and outcomes has fostered wider interest and engagement. TAP provides a climate that fosters and encourages partnership working with external agency practitioners, who, during feedback, have recognised TAP as a valuable resource to help them fulfil their goals of improved outcomes.
Future plans
TAP aligns with the Anticipatory Care operating model and the NHS Long term Plan and as such TAP would be replicable in other Cities where there is a desire to move to a person-centred outcome. Locally, we are now looking to have TAP Coordinators as part of the hospital discharge teams supporting those with complex health and social care needs and the professionals working with them.
