CCG Review of Progress and Priorities Helen Ruffell Operations Manager

360o Stakeholder Survey 2017-18

Survey Response Rate

Working collaboratively across South Tyneside to improve health and commission excellent healthcare

Strategic Goals We want people to be able to take greater responsibility for their own health We want people to be able to stay well in their own homes and communities We want people to receive timely and appropriate complex care People take greater responsibility for their own health The development of services that support people to stay well and take increased responsibility for their own health and wellbeing People stay well in their own homes and communities The development of primary care and community services to support people in a community-based setting and provide a point of ongoing continuity, which for most people will be general practice People receive timely and appropriate complex care The freeing-up of hospital based specialist resources to be responsive to episodic events and the provision of complex care and support and specialist advice to primary care.

Work Programme Strategic Goal Delivery Aims Work Programme People are able to be able to take greater responsibility for their own health  Development of services that support people to stay well and take responsibility for their own health and wellbeing Prevention and self-care Lifestyle strategies Cancer Frailty  People are able to stay well in their own homes and communities    Development of primary care and community services to support people in a community-based setting and provide a point of ongoing continuity, which for most people will be general practice Out of hospital care Primary care strategy End of life care Long Term Conditions Integrated commissioning e.g. children, Learning disabilities, continuing healthcare, CAMHS People receive timely and appropriate complex care Freeing up of hospital based specialist resource to be responsive to episodic events and the provision of complex care and support and specialist advice to primary care Path to Excellence Urgent care system Health Pathways

Timely and appropriate complex care

Elective Care

Cancer

A&E

Stroke

Work Programme Path to Excellence (Phase 1) Urgent Care System Urgent Care Hub Pressure on A&E Health Pathways Standardised pathways and education Rapid advice and guidance Urgent care – people turn up in A&E, not emergency. Need to get better at making sure people get to the right place – stream them better. Work ongoing on Urgent Care Hub. Struggle to deal with big numbers, people need to stop going unless they really need to be there. Lead project for action on A&E (national approach).

Staying well in homes and communities

South Tyneside Residents Population Shift (2014 to 2039) Change by Age Band (people in brackets) 0-19 1.5% down (500) 20-44 4.7% down (1,300) 45-64 31.4% down (13,300) 65+ 48.6% up (14,000) 75+ 73.7% up (10,100) 85+ 100% up (3,900) Deceased patients removed from this and further analysis Approaching 50% of patients within scope of local or national frailty work Moderately / severely frail under 65s a current gap Housebound 43.0% up (1,440 people) Care Home Residents up 40.7% (671 people) Partners in improving local health

COPD Prevalence

Preventable Early Mortality

Delay & Reduce the Burden of Long Term Conditions Access to the right care at the right time Early & Accurate Diagnosis Support to Self Care and Reduce Risk How do we integrate across the system? How do we reduce inequalities? How can we be more proactive? How do we make this easier for everyone?

POPULATION SEGMENTATION 7+ LTCs, EoL, care home, housebound SEVERE MODERATE MILD FIT 7+ LTCs, EoL, care home, housebound 4 – 6 long term conditions 2 – 3 long term conditions 0 – 1 long term conditions

Primary Care Strategy Stakeholders working together to deliver primary care at scale Reducing variation Changing the focus of primary care Improving Access to Primary Care Workforce planning These were the original slides that were used in mid 2016 to frame the strategy – they remain the same although over time we have considered the ‘Stakeholders working together to deliver primary care at scale’ to be more of an underpinning theme or approach rather than a workstream in its own right.

Extended Access Launched September 2017 3 hubs (rotating across 13 practice sites) 78 extra hours per week in 2017/18 117 extra hours per week in 2018/19 Over 10,000 additional appointments offered Book through Practice or 111

Work Programme Out of hospital care Integrated commissioning Community integrated teams Children Unplanned care Learning disabilities Primary care strategy Continuing healthcare End of life care Mental health CAMHS Long term conditions

Taking greater responsibility for own health

Smoking in Pregnancy Rate

Smoking in Pregnancy

Work Programme Prevention and self-care Cancer Lifestyle strategies Screening Relaunch “A Better U” Early diagnosis and treatment Lifestyle strategies Frailty Alcohol Proactive case identification Diet Smoking Early diagnosis and support Activity

“What matters to you?” rather than “What is the matter with you?”