Edinburgh Integration Joint Board Draft Strategic Plan 2019 – 2022

Honest and transparent Vision and Values Inclusive Honest and transparent Working together Empowering Integration Joint Board Vision Statement: ‘Working together for a caring, healthier, safer Edinburgh’ Quality Dignity and Respect Care and compassion Forward thinking Put people first

The Strategic Plan Parthenon Principles + Three Conversations Ageing Well Thrive Edinburgh Learning Disabilities Physical Disabilities Primary Care Enablers Directions

Three Conversations Our Priorities Conversation 1: Listen and Connect Conversation 2: Supporting people when they are at risk Our Priorities Conversation 3: High quality, person centred on-going support

Conversation 1: Keeping people well in communities - “Listen and connect” Supporting people to stay well in communities by: Having a focus on prevention - helping people build and maintain social networks, preventing falls, increasing physical activity, supporting unpaid carers and intervening early when long term conditions develop are key components of our approach Ensuring we deal with people’s concerns there and then as much as possible when they first get in contact with us (e.g. Through social care direct) Continuing to support our colleagues in General Practice Influencing the development of housing to enable people to stay well at home Maximise the use of technologies which can support people to stay well

Conversation 2: Providing the right care, at the right time, in the right place - “Support in times of crisis” The use of statutory services, including bed based hospital services, is a key part of what we want to commission, but we want to see these as the last option; and that we use them for the minimum possible period of time, with clear therapeutic intent. We want to help people return to as much independence as possible in their own homes and communities. Our pathways and planning will be focussed on community services as the front line and to shifting resources to support this as much as we possibly can. For example, in both the mental health and disabilities plans there are descriptions of how we are reducing bed numbers in hospitals and adding additional resources in the community

Conversation 3: High quality, person centred on-going support - “A good life” If people do need long term care, we are taking steps to create the capacity in the community so that people can receive care at home or in a care home. This includes making sure we support people to get the care which fits their individual needs by having good conversations with them and considering the other assets that people already have in their lives. Our “good conversations” training enables these conversations to take place and we need to ensure that SDS options are fully utilised so that people are empowered to plan their care

Enablers Carers Workforce Housing Transport Engagement and communication Equalities Transitions Commissioning Approaches Shifting the balance of care Long Term Conditions Technology and systems Volunteering

The Appendixes... Appendix 1 – Edinburgh Health Information Key Issues Appendix 2 – Long Term Conditions Plan Appendix 3 – Health and Wellbeing Outcomes Appendix 4 – Ageing Well Commissioning Plan Appendix 5 – Thrive Edinburgh Commissioning Plan Appendix 6 – Learning Disabilities Commissioning Plan Appendix 7 – Physical Disabilities Commissioning Plan Appendix 8 – Primary Care Commissioning Plan Appendix 9 – Housing Contribution Statement Appendix 10 – Directions

Appendix 1 - Edinburgh Health Information Update to the Joint Strategic Needs Assessment (JSNA) conducted in 2016. Highlights key issues for the population of Edinburgh City which informs planning: Edinburgh’s population in 2017 was 513,210. In 2041, population is projected to be 583,135 (high working age population, ageing population) Life expectancy at birth in 2017 for males in Edinburgh was 78.0 for males and 82.2 for females As people live longer, they live with chronic conditions and multimorbidity The existence of health inequalities cannot be attributed to a single clinical or behavioural risk factor. They are the result of social circumstances

Appendix 2 – Long Term Conditions Commissioning Plan Specialist community health teams (such as the Community Respiratory team) COPD integrated care model Physical Activity – fit for health Community Falls Anticipatory Care Planning Supported self management and digital support

Appendix 3 – Health and Wellbeing Outcomes Outcome 1: improve health and wellbeing Outcome 2: support to live in the community Outcome 3: positive experiences and treated with dignity Outcome 4: quality of life Outcome 5: reduce health inequalities Outcome 6: support for carers Outcome 7: safety Outcome 8: engaged and supported workforce Outcome 9: use of resources

Appendix 4 - Ageing Well Commissioning Plan Keeping people well at home for as long as possible (e.g. Befriending) Making sure people are aware of what services are available and how to access them (e.g. Social care direct and information) Ensuring our community based services are working together and as efficiently as possible (e.g. H@H expansion) Supporting the future of long term care (e.g. Sustainable contracting) Exploring and defining requirements for bed based models of care in the future (e.g. HBCCC)

Appendix 5 – Long Term Conditions Commissioning Plan Appendix 5 – Edinburgh Thrive Commissioning Plan Building Resilient Communities – e.g. Greening Up, GameChanger, A Sense of Belonging Arts Programme, LGBT Mind Matters Programme A Place to Live – e.g. Graded Support: making sure the environment “fits” the person’s needs Get Help When Needed – e.g. fewer beds in acute hospital, more community based provision delivered in partnership Closing the Inequalities Gap – e.g. housing first Rights in Mind – e.g. Peer led self help groups Meeting Treatment Gaps – e.g. matched care model for women with multiple and complex needs

Appendix 6 – Learning Disabilities Commissioning Plan The redesign of the Royal Edinburgh Hospital will require 19 community placements, additionally the partnership will commission from NHSL 15 beds for assessment and treatment Earlier intervention in childhood for people with behaviours that are challenging and development of smoother transitions from children to adult services Identification of a range of housing and support options for people with learning disability with a particular focus on core and cluster services How self-directed support can improve people’s lives. How integrated services can increase access to and benefit from improved Health and Wellbeing support.

Appendix 7 – Physical Disabilities Commissioning Plan PD Pathway Principles  The importance of accurate person-centred multi-disciplinary assessment Having clear criteria around services is important e.g. what identifies when someone requires in-patient v out-patient service, intensity and duration Person-centred goal setting Introduce in-reach and outreach work to facilitate effective and timely transitions between hospital and community and encourage better continuity of support for the person Disability is identified as being the person’s perception of their needs Training of the workforce is essential to further extend roles and support people

Appendix 8 – Primary Care Commissioning Plan The draft plan is shaped around the National Primary Care outcomes framework developed by Scottish Government Primary Care Improvement Plan is a key document and informs the strategy The plan builds on existing good work in Edinburgh to support general practice to be sustainable, such as recruiting different health and social care staff in general practice Highlights work required to develop physical and digital infrastructure in general practice General practice is supported to continue to address health inequalities and general population health

Under Development... Appendix 9 – Housing Contribution Statement Appendix 10 – Directions

Celebrating Success so far... Over 700 people have already given been involved with various elements of this plan We have had reference and working groups which have worked together to co-produce the commissioning plans The SPG have shaped the vision, values and priorities for the plan based on those of the previous strategic plan

Timeline for engagement 30th November 2018 1st Draft to SPG 14th December – 2nd January 2019 2nd Draft created based on SPG feedback End March 2019 2nd Draft edited based on feedback Early April 2019 Plan published Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 Mar 19 Apr 19 14th December 2018 1st Draft to IJB 3rd January – 21st March 2019 2nd Draft out for wider consultation with key stakeholders End March 2019 Final draft comes to SPG and IJB for final sign off