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

Sutton CCG and LB Sutton have come together to develop and deliver a joint strategy 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. Sutton CCG and LB Sutton have come together to develop a joint strategy and this presentation sets out the following: Our joint vision to reshape health, social care and wellbeing services The aim for our joint Strategy for Health and Social Care Our four key objectives Our five priority areas Where we will be in 2016/17 Our governance structure moving forward

The demand and challenges to our services 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 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 Kingston St George’s St Helier Croydon Sutton’s A&E demand has remained stable for the past 3 years SUTTON Non-elective admissions have increased by 3%,with spend increasing by 14% in the past 3 years Jubilee Health Centre Non-elective admissions for people aged 75 years and over, is much higher than across other age groups at 9% Older people currently make up 73% of adults with eligible social care needs.

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.

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

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.

Why do we need a joint health and social care strategy in Sutton We therefore aim to meet the following reductions in demand: 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 10% Reduction in A&E 17.5% Avoidable NEL admissions 25% Reduction in hospital-based outpatient appointments 5% Reduction in outpatient appointments

We have four main object Objectives Prevention Supporting people to maintain their independence Reducing admissions and lengths of stay in acute hospitals Improving quality of care 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 1 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 2 Planned Care – focus on ensuring that the right services are available to people in settings close to their homes 3 Older People – care for older people in Sutton will be provided as part of an integrated Older Patients pathway 4 Providing Services Closer to Home – expansion of community-based care to ensure more services are provided closer to home 5 Urgent Care – redirecting people with urgent needs away from acute services to community-based services where secondary care is not required

Long term conditions 1 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

Planned care 2 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

Older People 3 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

Providing services closer to home 4 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

Urgent care 5 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

Delivery Plans to support our strategic aims and objectives 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

Our governance structure moving forward 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. Health and Wellbeing Board One Sutton Commissioning Collaborative Transformation Programme board Long Term Conditions Workstream Planned Care Workstream Older People Workstream Urgent Care Workstream Prov. Services Workstream

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