Inspiring Communities Together Bernadette Elder – Inspiring Communities Together

Inspiring Communities Together Neighbourhood based charity Membership led – Trustees elected through membership Delivers activity – learning and volunteering Facilitates – bring people together through two local forums Advocate – link between agencies and local community Securing resources – paid work linked to aims Integrated Care – Community Asset theme lead http://inspiringcommunitiestogether.co.uk

Strategic Context Salford care economy Salford Together Partnership Urban area in Greater Manchester Population of circa 230,000 Area of significant deprivation and health inequalities Largely co-terminus - Salford CGG (health commissioner) - Salford Royal (acute and community healthcare provider) - Salford City Council (adult social care) - Greater Manchester West (mental health provider) Long history of successful partnership working Salford Together Partnership Four high performing partners – within broader network of partners £98M Pooled Budget - Integrated Care for Older People (ICP) Governed by Alliance Contract Underpinned by 2014-18 Service and Financial plan (inc. BCF) Formal Programme Management approach (ICP) ICP one of three major transformation initiatives Out of hospital Care (primary care investment, renewal) & HT 3

The Start of this Journey… Significant population growth High levels of need Poor experience of care Significant cost of care Service duplication National and international evidence “Integrated health and social care for older people has demonstrated the potential to decrease hospital use, achieve high levels of patient satisfaction, and improve quality of life and physical functioning” Curry and Ham, Clinical and Service Integration – The Route to Improved Outcomes King’s Fund, 2010 4

Salford’s Integrated Care Programme 1 Promoting independence for older people Better health and social care outcomes Improved experience for services users and carers Reduced health and social care costs 3 2 Local community assets enable older people to remain independent, with greater confidence to manage their own care 1 Housing Work stream Centre of Contact acts as an central health and social care hub, supporting Multi Disciplinary Groups, helping people to navigate services and support mechanisms, and coordinating telecare monitoring 2 Multi Disciplinary Groups provide targeted support to older people who are most at risk and have a population focus on screening, primary prevention and signposting to community support 3

POPULATION STRATIFICATION Wellbeing Plan Sally’s standards Able Sally 71%: c. 24,850 GP standards Independence Plan Needs Some Help 17%: c.6,000 Carer support and disease management Supported Independence Plan Needs More Help 9%: c.3100 Home care and intermediate care standards Care Plan Needs A Lot Of Help 3%: c.1050 Care Home standards SHARED CARE PLANS STANDARDS 6

2020 targets – Emergency admissions and readmissions 19.7% reduction in NEL admissions (from 315 to 253 per 1000 ppn) Reduce readmissions from baseline Cash-ability will be effected by a variety of factors Permanent admissions to residential and nursing care 26% reduction in care home admissions (from 946 to 699 per 100,000 ppn) Savings directly cashable but need to be offset by cost of alternative care (especially increased domiciliary care) Quality of Life, Managing own Condition, Satisfaction Maintain or improve position in upper quartile for global measures Use of a variety of individual reported outcome measures Flu vaccine uptake for Older People Increase flu uptake rate to 85% (from baseline of 77.2%) Proportion of Older People that are able to die at home Increase to 50% (from baseline of 41%)

Alliance Agreement Lead Commissioner BENEFITS P BENEFITS Full range of services within a single management arrangement – more effective, efficient and coordinated care Collaborative environment without the need for new organisational forms Aligns interests of commissioners and providers, removing organisational and professional ‘silos’ that contribute to fragmented and sub-optimal care Collective ownership of opportunities and responsibilities; any ‘gain’ or ‘pain’ is linked to performance overall Supports a focus on outcomes and incentivises better management of population demand CCG, City Council, SRFT, GMW, Salix Health, social care & wellbeing for 65+ population £98m pooled budget Some services subcontracted Phased introduction 2014/15 onwards 8

Integrated Care -> ICO Capitalise on our common purpose, strong relationships, and our success Extend the vision: Population Health Improvement beyond “out of hospital care” Single system of governance for health and social care Full population list Strategic commitment to develop an ‘Integrated Care Organisation’ – initial focus on adults and older people 9

Realise the Vision… Objectives Integrate commissioning Single pooled budget across health and social care Single strategic vision, robust governance & shared decision making Pathway to single capitated budget Create an Integrated Care Organisation Prime provider model SRFT Lead - direct provision of health and adult social care. Supply chain Transform and Integrate Primary Care Investment for renewal – workforce, larger footprint - critical mass, estate Range of models to involve general practice as a partner Transform Urgent and Intermediate Care System redesign, optimal use of estate Radical shift towards new technology and telemedicine Preventative, planned care in community and residential settings Highest quality, safest, most productive H&SC system in England Shift away from institutional settings Empowering, anticipatory model of care – delivered in or near the home 10

Benefits - Outcomes Population System level Staff More personalised care – in or near the home Significant reduction in avoidable admissions to hospital and care homes Improved quality of life for users and carers Significant increase in the ability of people to manage their own condition System level More resilience, flexible governance to target resource around fluctuating need New relationship with the community – accountable in one place to shape the system to meet demand with better outcomes, improved experience and greater efficiency Highest quality, safest, most productive health and social care system in England Staff Most attractive workplace in England Reorganisation around the needs of the citizen New roles and greater career development opportunities 11

Implementation Challenges As a Vanguard Site, Salford is ready to meet the implementation challenges ahead Where Salford can contribute straight away Integrated Care Programme Management Alliance Contract Management Whole system quality improvement e.g. Haelo Longitudinal evaluation with academic partners e.g. CLASSIC Support Salford is interested in accessing Implementation resource Due Diligence – Legal Challenges Liaison with National Bodies – Access to thought leadership e.g. General Practice Contractual / Payment Systems – risk sharing Extension of CLASSIC programme 12

Community Asset model “Using the knowledge and life experiences of older people to make life better by listening to and valuing their views: making sure this influences services to be better in future by building on community strengths. This will keep older people in Salford healthy, happy and independent for longer”

Engagement The Citizen Reference Group (CRG) This formal structure was established as part of the ICP programme. The group of local older people are supported through a development worker and meet monthly to look at aspects of the programme – acting as a critical friend. Members engage with areas of work which interest them and act as ambassadors for the programme by sharing key messages from the programme with their own networks. The community asset work stream project group have engaged with older people through the network of partners who attend the monthly meetings (housing providers, development workers, third sector organisations, health workers and Salford City Council). Older people are invited to take part in workshops and focus groups to understand what is important to them to support their own health and well being.

Community asset work stream project group Community asset model An Age Friendly City – the commitment of the city to support older people to stay healthy and well. Older Person Standards and Well Being Plans- the commitment by older people to support their own health and well being. A set of tools developed by and for older people based in local neighbourhoods – the commitment of community and deliverers to support older people to stay healthy and well Community asset work stream project group The network includes a wide range of partners including mature people, City Council , University, Businesses, Charities, Social Enterprises, and Third Sector, Work across a number of areas including housing, volunteering, befriending and Leisure and Health Improvement connections. Matt – Martin to lead the session

Community asset approach Ensure there is access to advice and guidance for older people to stay healthy and well and manage their own health and well being at a neighbourhood level with a focus on prevention and well being Ensuring there is opportunity to access activity at a neighbourhood level and funding to support new activity Developing technology as a tool for improved health and well being Building volunteering as a life choice in older age and linking to the centre of contact and community connectors model Joining up what is already happening

Cost and value to the NHS Loneliness = £ to some one who smokes 15 cigarettes a day Falls = over 4 million NHS bed days each year 14% (nearly 5000) of people aged 65 and over may be at risk of malnutrition (using BAPEN prevalence tool) Bad oral health leads to poor levels of nutrition & can lead to social isolation Technology can be a means to enable older people to renew and develop social contacts and engage actively in their communities. Matt – Martin to lead the session

Barriers Improvement measures Community asset tools Reduce impact of Prevention and well being Oral health Malnutrition Step up Tech and tea Neighbourhood activity and fund Volunteering Community connectors Well being plans Social Isolation Loneliness Depression Not eating well Not engaged Lack of access to information Limited physical activity Improvement measures Barriers Reduce impact of Social isolation depression loneliness Reduce emergency admissions Improved quality of life for users and carers Increase the proportion of people that feel supported to manage own condition

CA budget 2015/16= £500,000 Asset mapping – development support to understand what we have and identify gaps and opportunities Prevention and well being – Step up programme and advice and guidance including development of tools with older people Neighbourhood activity - funding to support access to activity at a neighbourhood level and support new activity Technology – tech and tea across the city as a tool for improved health and well being Volunteering as a life choice in older age Delivered by 3rd sector in the community to support activity already being delivered

Meeting the targets Improvement measures: Technology as a tool to increase the proportion of older people that feel able to manage their own long term condition and improve the quality of life for users and carers  Prevention and well being activity ensuring there is access to activity, advice and guidance for older people to stay healthy and well and manage their own health and well being at a neighbourhood level with a focus on prevention and well being. This will help reduce emergency admissions and readmissions. Neighbourhood activity ensuring there is opportunity to access activity at a neighbourhood level and funding to support new activity to increase the proportion of older people that feel able to manage their own long term condition and improve the quality of life for users and carers

Demonstrating the difference Quality improvement: A test and learn approach – Small scale test and rapid scale up based on evidence – dash board of measurers: Loneliness tool Well being plans Digital skills Increase in volunteers increased community resilience Improved level of fitness measurers Increase in awareness of eating well in later life quiz High level evaluation - CLASSIC: Improved quality of life measurers

Moving from health to well being Medical model Hospital to home – Salford Home Safe In own home – Multi Disciplinary Groups (MDG) Centre of Contact GP Surgery Asset based model Building on individual strengths Using the right tools – well being plan/Setting personal goals Joining up what is already happening and flipping the axis to support the best outcomes for the person as safely and as quickly as possible Matt – Martin to lead the session

Home support Hand holding Sign posting Wellbeing Plan Medical support Ready to manage own health Home Safe CA coordination group Hospital Home support Confidence bld Care on call Health Trainers Befriending housing Community assets MDG Hand holding Centre of Contact Well being coaches Sign posting GP surgery Health Improvement Neighbourhood management Reconnecting individuals to the community

Opportunities and challenges Community Asset approach recognised as part of the solution Budget allocation – Lowest % at present Starting to demonstrate impact = £££ VCS as partners in coproduction of model Challenges: Moving funding outside the system VCS working in partnership – Salford approach 3SC (86 members) Large contracts V small scale neighbourhood interventions Matt – Martin to lead the session

Thank you for listening – For further information http://www.salfordtogether.com http://inspiringcommunitiestogether.co.uk bernadette@inspiringcommunitiestogether.co.uk Matt – Martin to lead the session