February 28, 2025

Case Study: Connected Care Network, Birmingham

The Connected Care Network in North Solihull are using Joy to digitally enable an integrated VCSE model for Children & Young People. The case study was originally published by NHSE Guidance on neighbourhood MDTs for CYP.

Introduction

Inspired by the Connecting Care for Children model in London, Connected Care Network (CCN) was established in North Solihull, Birmingham. It operates across health, education, social and voluntary and community sectors, shifting away from standardised solutions in favour of an approach that considers local relationships, demographics and need. The CCN aims to provide a digitally enabled, integrated model of care that ensures the right care at the right time in the right place.

The commissioning of 2 local VCSE organisations as lead delivery partners demonstrates how bringing together the health and VCSE sectors can deliver holistic, integrated care in a community.

The model also focuses on enabling children and young people and their family and carers to “tell the story once”, reducing the frustrating burden on families to repeat their needs.

Local context

The North Solihull primary care network is the largest in the Birmingham and Solihull ICB, with approximately 20,000 registered children and young people. 100% of the population lives in neighbourhoods classed as the most deprived 20% in the country, with more than 50% living in the most deprived 10%. 30% of under-5 years are defined as living in poverty. 21% of children and young people living in North Solihull have special educational needs, compared to the borough average of 15%.

The Joy App has been pivotal in providing an ICB-approved software solution for integration. This platform connects with primary care clinical systems and is flexible enough to be suitable across organisations. Alongside an intuitive client management system, the ability to track referrals and record outcome measures has made it core to the CCN’s integration success.

Service evolution

Extensive stakeholder engagement was carried out with children, young people, family, carers and key stakeholders at “place” and commissioning level to determine local priorities. This led to joint planning and pooling of resources from various agencies.

2 of the lead delivery partners are part of a well-established and connected network of VCSE organisations focused on children and young people. This was made possible by providing contracting and funding through the ICB, with the full-scale model operating from August 2023.

Local partners from across the system continue to join, enabling the CCN to expand its breadth and reach. The CCN prioritises identifying and using existing processes, teams, professionals and organisations. Where gaps are identified, the CCN takes the lead in creating new pathways to address these. This has often meant needing to find new funding and grants.

The key workforce across the primary care network is:

GP clinical lead
health and wellbeing coordinators (band 4)
operational lead (band 5)

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Service delivery

1. Case identification

Referrals are received from local professionals through an online referral form, co-ordinated by the Joy App. There are no referral criteria other than a professional requiring support to address a need they have identified for a child, young people, family or carer.
The top 5 referring agencies to the CCN are primary care, schools, Solihull Youth Justice Service, the local authority inclusion service and VCSEs.

2. MDT case discussion and triage

Triaging of needs is facilitated by completing a holistic “tell the story once” form with the child or young person and their family or carer. While this is usually completed by the care co-ordinator following referral, a deliberately flexible approach allows other professionals, including psychologists, teachers, family support workers or GP to complete the form if more appropriate.
All referrals are discussed at a weekly MDT to identify the most appropriate support and create a plan of action.
The core attendees at each MDT include the GP clinical lead, the health and wellbeing co-ordinators, the operational lead and VCSE organisations representatives. Any professional is welcome to join, with the core group maintaining links to wider professionals for specific guidance as required.
The outcome of the MDT discussion and plans for follow up are communicated to the child or young person, family, carer and referrer via the Joy App.
The CCN MDT completes all recommended referrals to local services, agencies and organisations including forwarding the completed “tell the story once” form to reduce the burden on children, young people, families or carers of having to repeat their story.

3. Direct care

The GP clinical lead provides 2 telephone clinics per week, primarily for children and young people with long-term health conditions or challenges navigating the health system.

4. Professional knowledge sharing

The evolution and success of the CCN has been based on professional relationship building, trust and delivering positive outcomes across the board and across the system
Partnership working has facilitated improved local care pathways, including a new dental pathway with direct referral established through the CCN.

5. Children, young people, family and carer engagement and health promotion

Stakeholder engagement and co-design have been prioritised from the outset to identify local needs and tailor the CCN model to these.
Early recognition and intervention to meet low-level needs is provided through family support home visits, workshops, parent meet-ups and signposting.
The CCN works with social prescribing teams, community development teams, VCSE organisations and schools, leveraging local resources and knowledge to find tailored support for local communities.
The CCN supports children and young people while on waiting lists for specialist services. Additionally, the service has evolved to address unmet needs that were identified through local evaluation – specifically for help with sleep and diet. Early-stage development of a pathway for care-experienced children and young people is also underway through partnership working with specialist nurses.

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Impact

Children, young people, family and carer experience

The “tell the story once” approach has received positive feedback from families. It addresses a priority identified in stakeholder engagement by reducing the need for families to repeatedly share their stories to multiple professionals and services.

Clinical outcomes

In the first 6 months of the pilot, the CCN found:

an average 56% reduction in all self-reported issues
90% of children and young people reported an increase in being able to better manage their long-term health condition
63% reported improvement in managing day-to-day mental health needs
44% reported a reduction in feeling socially isolated
75% felt more supported in their education

System efficiency

Data comparing practices have shown CCN leads to:

25% fewer referrals into community CYPMHS
40% fewer referrals to autism assessment services
27% fewer referral to community paediatrics

Estimated cost savings (in April 2024, based on 427 cases referred) include:

569 GP appointments saved (saving approximately £17,000)
reduction in outpatient appointments for 12% of children and young people (saving an estimated £10,400)
5,124 hours of support provided outside clinical and therapeutic support (saving over £400,000)

These estimated savings relate to health services; the CCN also anticipates savings across the broader system (for example, education) and the child or young person’s life course.

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System co-ordination

The Joy App enables streamlined referrals and flow of information between professionals and services that support child and young people, thereby building capacity.
It also enables data collection and outcomes measurement across the system partners. Stakeholders have provided positive feedback on the system’s user friendliness and capabilities.

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