Challenges Objectives CCG Led Initiatives Vision ‘How’ Outcome Aspirations Better integrated health and social care Improve the health and wellbeing of all local people Underpinned by effective clinical decision making Prevention, empowerment and resilience Seamless integrated pathways Clinical relationships and increased standardisation Raise awareness of lung cancer to patients over 50 years attending COPD, CVD and Smoking cessation clinics Implementation of NICE guidance re: referrals for coughs lasting over 3 weeks Play an active role in the delivery of the Health and Wellbeing Strategy Life expectancy at 75 - i: males,ii :females Review of Dermatology Services Reduce outpatient first attendances and follow up (QIPP) - through exploring variation in outpatient referrals QP Initiatives Integrated urgent care response, easily accessible at the appropriate level TBC Improving the quality of care for people with COPD across the whole system Standard admission assessment to all GP Practices Identification and treatment of people with AF at risk of a stroke Development of revised service model for Diabetes intermediate care service and modernisation of secondary services Review of Community Nursing and Community Matrons Review and implementation of changes to the District Nursing services Improve quality of care for long term conditions across the whole system Health related quality of life for people with long-term conditions EA’s for acute conditions that should not usually require hosp admission; Emergency readmissions within 30 days of discharge from hospital Collaboration with Sunderland University on clinical education Programme of Clinical Education with localities Use of QoF QP indicators with focus on peer review Development of Sunderland Information Portal with Practices Knowledge Management Every practice operating to agreed standards and pathways – working collaboratively with partners Patient Experience of Primary Care i: GP services ii:GP out of hours services iii: NHS Dental services Every practice to systematically improve the quality of prescribing adhering to evidence based guidelines Standard Assessment Process Community based service for Cellulitis Community based service for the assessment and diagnosis of suspected DVT Integration of 24/7 & urgent care teams TBC Future provision of health and social care in Sunderland - ‘Plan on a Page’ Re-model ling of breast cancer services Ensure cancer pathways are aligned to NECN model pathways (one stop shops) Radiotherapy strategy to secure local provision Consider future commissioning arrangements for health checks. CCG Supported Initiatives Implement 111 single point of access Urgent care transport strategy Review of Urgent Care Nursing Services across Sunderland Implement self care model for LTCs Commission new models and approaches to specialist rehabilitation Develop and commission an integrated model of intermediate care services Develop sustainable and successful reablement/readmission schemes Improve provision of heart failure services across primary, community & secondary care Improve discharge processes Single-site model for weekend TIA clinics Implement revised carpal tunnel pathway Increase GP access to some diagnostic tests Review adult hearing services (AQP) Review podiatry services (AQP) Every practice to optimise screening and early identification opportunities Integrated tiered approach to Mental Health across the whole healthcare system Potential years of life lost from causes amenable to healthcare TBC Raise GP awareness re early diagnosis of lung cancer Implementation of physical Health checks in primary care for people with learning disabilities Bowel Cancer Screening awareness HPV testing for cervical screening Reprovision of inpatient,outpatient & community services Implement Mental Health Model of Care Access to MH Services pilot Excess cancer & CVD deaths Health Inequalities Financial constraints Over reliance on hospital care Growing elderly population Fragmented healthcare Better health for Sunderland Increase repeat dispensing rates Four drugs post-MI Moving spend per head of population Care Homes review Develop a LES for Shared Care Rationalise mental health prescribing Improve supply routes for a range of products Ensure formulary management plan in place Provide more planned care closer to home Patient experience of hospital care Patient Safety incidents reported Safety incidents involving severe harm or death

OUT

Excess preventable cancer & CVD deaths Poor quality of life No £ growth expected Increasing elderly population High hospitalisation Better Health Longer life, better quality of life, fair access, reduce inequalities Excellent Patient Experience Safe care, effective treatment, quality services, greater choice, improved access Wise use of the money Right services in right place first time, increased productivity and VFM, reducing duplication and waste PREVENTION LONG TERM CONDITIONS AND REHABILITATION SAFE, QUALITY SERVICES. CLOSE TO HOME. NO WASTE Increase Life Expectancy by Men 2.0%, women 1.1% Reduce Health inequalities by 5.2% Reduce Childhood obesity by 10% Stop the rise in alcohol related admissions Reduce hypertension in people with TIA / stroke 4% Increase breastfeeding by average 89% Reduce ambulatory care sensitive conditions by 44% Reduce Smoking in people with LTC by 29% Reduce smoking in pregnancy by average 26% Implementation of dementia strategy Increase deaths outside hospital by 5% Reduce CVD & cancer deaths Better start in life: Childrens health Maternity services Reform mental health care - more provided outside hospital Long term conditions Identification & management Better rehabilitation Reform urgent care for adults & children - more provided outside hospital Reform planned care - more provided outside hospital A better death, greater choice Obesity Smoking Alcohol Child Health Maternity CVD Risk Cancer LTC & Rehabilitation Sick & injured children Urgent care Planned care Mental Health End of Life Care  Evaluate new obesity services  Referral to lifestyle packages  Evaluate new alcohol services  Promote positive drinking culture  Rebalance stop smoking services  Deliver smoke free schools  Child health promotion  Children’s risk & resilience model  Increase breastfeeding  Review maternity staffing skill mix  Identify & manage high risk women  Reform care of sick & injured child  Single point of access  Integrate pathways across organisations  Diagnostic services in community  Telehealth  Wider LTC reform  Reform stroke rehab  Reform neuro rehab  Reform intermediate Care  CVD identification & management  Early cancer identification – awareness, screening  Reform programme shifting care out of hospital utilising PCCs  Rheumatology modifying drug monitoring in primary care  Carpal tunnel out of hospital  24/7 services in all settings  Review & redesign services using Marie Curie Choice programme  New model of mental health care  Implement dementia strategy  New model of CAMHS  Autism national strategy DriversObjectives Outcome Aspirations ProgrammesInitiatives Vision Strategies