Sutton CCG & LB Sutton PartnershipPresenting our joint health and social care strategy for Sutton

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Sutton CCG and LB Sutton have come together to develop and deliver a joint strategy

Sutton CCG and LB Sutton have come together to develop a joint strategy and this presentation sets out the following:

The aim for our joint Strategy for Health and Social Care

Where we will be in 2016/17

Our joint vision to reshape health, social care and wellbeing services

Our governance structure moving forward

Our five priority areas

Our four key objectives

• Sutton CCG became the statutory organisation responsible for commissioning health services for residents of Sutton in April 2013

• LB Sutton has a statutory responsibility to commission social care services for local residents.

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The demand and challenges to our services

SUTTON Non-elective admissions have increased by 3%,with spend increasing by 14% in the past 3 years

Older people currently make up 73% of adults with eligible social care needs.

Non-elective admissions for people aged 75 years and over, is much higher than across other age groups at 9%

Sutton’s A&E demand has remained stable for the past 3 years

There are 27 GP Practices, and the majority of unplanned and planned hospital admissions and care occur at St Helier Hospital and St George’s Hospital

Sutton has a population of approximately 192,000, of which: • Population over the age of 65 is

expected to increase by 18.7% between 2011 and 2021

• 79% of are white and 12% from Asian or Asian British ethnic groups

St Helier

St George’s

Croydon

Kingston

Jubilee Health Centre

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A new community service model for Sutton

Resulting from the demand and financial challenge, and in order to achieve a sustainable health and social care system fit for the future, service models in Sutton will need to adapt.

Co-commissioning between Sutton CCG and Sutton LB will be the mainstay of our Joint Strategy for Health and Social Care and commissioning intentions

Co-commissioning efforts will be reinforced through the Better Care Fund

The Better Care Fund (BCF) is recognised as a national enabler for integrated care. A joint pooled fund between Sutton CCG and LB Sutton will be created In Sutton, the minimum transfer from Sutton CCG to the BCF will amount to £614k in 2014/15, increasing to £14m in 2015/16.

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Our vision for joint health and social care in Sutton focusses on

This will involve a step change in the way that we plan care, from focussing on

reactively providing services when people fall ill, to creating a balance and

proactively supporting people to stay healthy.

Re-shaping health, social care and wellbeing services so that people are supported to remain well for longer in their own homes.

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By 2016, we will provide services that deliver high quality, integrated care to our residents

We will support our residents to remain as independent as they can for as long as they can. We will support and educate our residents to self-care where possible and we will prevent avoidable admissions to hospital providing alternative and responsive community services. We will encourage independent community-based living through joined up services and professionals working closely together. There will be strong relationships between commissioners and provider organisations so that we can realise our vision.

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Why do we need a joint health and social care strategy in Sutton

Our joint strategy will:

• build capacity in the community to work collaboratively through integrated services

• build capacity in the community to identify people at risk

• expand the capacity of the reablement and rehabilitation services

• realign the acute sector to match changing demands and community capacity

• maximise people’s capacity to self-care

• plan and develop a community workforce in collaboration with providers

• provide stronger links with voluntary services and other community groups

Reduction in A&E

Avoidable NEL admissions

Reduction in hospital-based outpatient appointments

Reduction in outpatient appointments

We therefore aim to meet the following reductions in demand:

10%

17.5%

25%

5%

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We have four main object

Prevention

Supporting people to maintain their independence

Reducing admissions and lengths of stay in acute hospitals

Improving quality of care

Objectives

Helping people to remain healthy by stopping them becoming unwell or preventing their condition exacerbating, avoiding unnecessary admission to hospitals or care homes

Providing more support in communities to help people effectively manage their own health and well-being

Providing alternatives to admission then improving discharge and building more effective reablement to ensure maximum patient independence

Following an episode of ill-health or crisis with the delivery of the right services, in the right place and at the right time

Our schemes are organised into five priority areas

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Long term conditions – as population over the age of 65 in Sutton grows, the number of people living with one or more long term conditions will increase. Focus on identifying people with LTCs and assisting with management and prevention

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Planned Care – focus on ensuring that the right services are available to people in settings close to their homes

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Older People – care for older people in Sutton will be provided as part of an integrated Older Patients pathway

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Providing Services Closer to Home – expansion of community-based care to ensure more services are provided closer to home

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Urgent Care – redirecting people with urgent needs away from acute services to community-based services where secondary care is not required

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Long term conditions

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•Proactive approach to identify people with multiple LTCs and focus on management and prevention•Reactive approach to ensure responsive services , professionals and expertise are in place to respond•Identify people at greater risk of unplanned hospital admission and support through active case management•Move away from a historic disease pathway focus towards a more integrated service

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Planned care

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•Expand the range of services which deliver community and specialist planned care•Providing services in convenient services, close to where people live•Support the continued relocation of services into the Jubilee Health Centre•Improved referral management to ensure appropriate planned care is delivered in the community

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Older People

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•As part of an integrated Older Patients Pathway provide improved quality of care to all people over the age of 65 •Further develop in-reach/out-reach from community and social services to provide better continuity of care and discharge planning•Embed care planning and a person-centred approach delivered by a team of key professionals who are connected with GPs and specialists•Improve discharge planning and provide expanded services which promote timely discharge and intensive community-based care to improve functionality, independence and prevent readmission

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Providing services closer to home

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•Develop community estates where people can experience community care, diagnostics and selected specialist care co-located on one site •Improve care and responsiveness for people who are discharged from hospital, including improving functionality, preventing social exclusion, supporting access and signposting to alternative services•Provide intense and timely access to intermediate care and rehabilitation •Support, respite and education to informal carers and family members

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Urgent care

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• Services schemes which provide responsive urgent care and rapid response interventions•A whole-system model which encourages prevention of admission and offers signposting

including Out of Hours and 111 services•Co-located in the emergency department is our Rapid response multidisciplinary team•Facilitating the implementation and development Ambulatory Care Service

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Delivery Plans to support our strategic aims and objectives

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• We have developed delivery plans for each of the priority areas outlining the key steps required in 2014/15 and 2015/16 in order to implement the individual schemes within each area. Commissioning managers from Sutton CCG and LB Sutton have outlined key milestones for in order implement new schemes and further evaluate and manage schemes over the next two years. The plans also outline the predicted outcomes that will be realised through execution of the schemes

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Our governance structure moving forward

Transformation Programme board

One Sutton Commissioning Collaborative

Health and Wellbeing Board

Prov. Services Workstream

Urgent Care Workstream

Older People Workstream

Planned Care Workstream

Long Term Conditions

Workstream

Reorganisation of our governance will be required in order to deliver our aims and objectives. The revised governance arrangements will be live from June 14.

In summary our joint health and social care strategic plan will help us to deliver…

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A whole-system service model which expands community-based health and social care, and improves the connections between primary care, third sector services and acute services

A proactive set of community-based services which are targeted at those who are at risk of escalating needs, and which will help to keep people out of hospital, independent and improves outcomes

A reactive set of community-based services which will be responsive for those people whose needs rapidly escalate, preventing inappropriate time in hospital and improved community-based rehabilitation and reablement

Shift and expansion of services which will bring high quality care and expertise closer to home

Strengthened relationships and governance between Sutton CCG and LB Sutton working in partnership with community-based and acute care providers