Berkshire West CCGs

Operating Plan Refresh

2015/16

Working together to

keep people well and out of hospital

Five Year Forward View

• New models of care and joint commissioning

• A stronger role for the voluntary sector

• Valuing the role of District General Hospitals

• Transformed primary care

• Greater emphasis on improving public health

• Patients more in control of their own care

• Better use of innovative technology

Changes needed

• New model of care provision which meets financial

constraints

• Coordinated “wrap around” care enabled by different

resourcing for primary, community and social care

• Hospital care delivered in the community

– building on the success of our diabetes work in Berkshire West;

professionals working together beyond hospital walls

• Focus on health and wellbeing, collaborating with

Public Health to support patient self care

Our focus areas

Hospital services

Urgent care system

Out ofhospital sector

Integrated primary, community

and social care at scale

The right care in the right place

• Physical and mental health needs of equal status

• Improving access to Mental Health services - particularly Tier 3 Child and Adolescent Mental Health

• Piloting new technology-enabled care

• Innovative approaches to transform clinical pathways

• Highly responsive urgent and crisis care services

outside of hospital

• Helping people to know where to go and providing better

information to support individuals to self care

• Meeting waiting time targets for A&E, cancer and

outpatients

Out of Hospital Services

• Better Care Fund to deliver more services provided

in the community, developed in partnership with

social care [example - Hospital at Home and Neighbourhood clusters]

• Primary care investment to place GPs at the centre

of coordinating care for people with long term

conditions

• A single point of access to health and social

services for patients, carers and professionals

• Responsive, integrated health and social care

services to get hospital patients home sooner

A Call To ActionThe vision of your local CCG

Dr Abid Irfan – CCG Chair

Our local Health Challenge• Age Profile: we have a larger proportion of older children aged 10 to 19 and adults aged

40 to 49; and a smaller proportion of younger adults aged 20 to 34

• Ageing population an anticipated growth in the over 65 population of 34% (or 8,000 people) by 2021

• Pockets of relative deprivation The most deprived areas are in parts of Greenham, Thatcham North and Victoria. Greenham is in the 20% most deprived nationally.

• Obesity Overall is lower than national average but approximately 30% of year 6 children are overweight or obese.

• Smoking prevalence lower than the national average.

• Disease prevalence: cardiovascular diseases, COPD, diabetes, chronic kidney disease, mental health disorders, depression and dementia are lower than the national prevalence rates and comparator CCG group. The prevalence of asthma is higher.

• New models of care and joint commissioning

e.g. Diabetes, chronic respiratory disease and Hospital at Home.

• Transforming primary care

e.g. Increased Access (Winter pressures & Saturday Opening) and focus on Admissions avoidance through Community Enhanced Services

• Greater emphasis on improving public health

e.g. Pre Diabetes and Health Checks

• Parity of Esteem for Mental Health Services

e.g. Hospital Psychiatric liaison service and Crisis Concordat. Support for carers. Focus on Dementia

• Better use of innovative technology

e.g. Connected Care project (MIG & Orion), DXS, E-prescribing, tele consultations

Delivering in line with the NHS 5 year forward view

Operating Plan refresh 2015/16 -Local objectives

• Draft ‘Plan on a Page’ within welcome pack showing refreshed commitments, alongside examples of areas we have focussed on following previous Call to Action events. Feedback welcome

• Promote healthy lifestyles in partnership with Public Health

• To develop a sustainable model of Primary Care locally.

• Continue to Increase the timely diagnosis of dementia rate

• Work in partnership across Berkshire to improve outcomes for people experiencing mental health crisis through the crisis concordat, street triage and increasing self-referrals to talking therapies.

• Create joint system-wide integrated pathways across key areas such as frail elderly. Develop new models of delivery of care.

• Continue to deliver our constitutional commitments such as bringing health and social care system together to ensure consistent delivery of the 4 hour A&E target, 18 week waits and Cancer

• Ongoing development of services at West Berkshire Community Hospital

Importance of integration with Social care

Introduction to Tandra ForsterHead of Adult Social Care West Berkshire Council

Importance of integration

with Social care

Tandra Forster

Head of Adult Social Care

The headlines

Challenges

Austerity

Health funding gap from rising demand is set to be £30bn by 2021

(Nuffield/NHS)

Local Government Association project gap in local government funding of

£16.5bn by 2020

Ageing population

By 2030 the number of older people with care needs is predicted to rise by 61%

Ageing workforce – recruitment challenges

Burden of disease

People with Long term conditions account for 70% of health and care spending

As of 2011, 52% of over 65s had a limiting long-term health condition or disability

– a 50% increase since 2001.

Key drivers of change

Care Act 2014 – more challenge

Embeds personalisation

Opens up key role of carers

Wellbeing

Prevention

Good quality information and advice

Robust care market – quality and choice

Caps the cost of care to the individual (April 16)

‘Whole Place’ approach to Health and Social

Care Integration

Health and Social Care is a complex network with many

different essential services

Better Care Fund - government initiative to kick start

integration

We need to focus on:

Developing a shared understanding of local need

Plan together

Integrate services

Making change happen

Service improvement by improving:

Communication

Coordination

Teamwork

Simplification

Aligned budgets

Shift our focus

Focus on strengths not deficits

‘Doing with, not to’

Part of the solution

Creating resilient communities

Vision for 2019

Person centred services that focus on outcomes rather than outputs

Provision of good quality information and advice that empowers people to make

good choices and self-manage

Flexible services that operate across 7 days where appropriate.

Services will be simpler to access, have less duplication and reach service

users/patients earlier.

Delivery of health and social services to be localised wherever possible including

access to crisis,

A greater range of local services that promote independent living

Reduction in avoidable hospital admissions.

Lengths of stay in Hospitals will be kept to a minimum

Increased numbers taking up of personal budgets

Angus TalliniGP Lead for Primary Care NDCCG

5th March 2015

Monday Morning…

Rising Demand from multiple sources, including GPs themselves

Demographic changes

Workforce changes

Organisational factors

Hospital care

Urgent care

system

Out of hospital sector:

Integrated primary,

Community and social care

at scale

Alleviating

current pressures

Effective co-

commissioning of

primary care

services

Incentivising

innovation

A Rewarding Place to Work

– with a training focus

Offering timely appointments over extended week in accordance with

patient need

Integral part of urgent care

system

Continuity where it matters most to give

proactive and coordinated care for

‘at-risk’ patients

Preventative

Supporting patients and their

carers to self manage

Long Term Condition

Fit-for-purpose premises

Sustainable and good

value

Signposting to facilitate

appropriate usage of GP and wider

services by patients

Continuing to provide high quality care

Using Technology to

optimum effect

Offering defined level of care

through varying delivery models

Comprehensive Directory of Services and active signposting at the front door

Supported self care extending to long term conditions

Continuity when it matters mostwith a team supporting each GP within the practice

Urgent primary care capacityco-operative approach to on the day demand