@jitscotland JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Dr Anne Hendry National Clinical Lead for Integrated Care The Scottish Approach to Integrated Care

Public Service Reform in Scotland

Public Finances – Fall in Government Expenditure

Projected % change in Scotland’s population by age group,

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 5 Reshaping Care for Older People 10 Year Programme to 2021 £ 300 million Change Fund Partnerships between NHS: primary, acute, mental health LA: social care & housing Third and Independent sectors Older people and carers Change Plans signed off by all partners 20% of funding to be invested in direct or indirect support for carers

Reshaping Care Pathway

People living in more deprived areas in Scotland develop multiple conditions around 10 years before those living in the most affluent areas

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Scottish Election 2011 Scottish National Party69 Scottish Labour Party37 Scottish Conservatives15 Scottish Liberal Democrats 5 Scottish Green Party 2 Other 1

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Public Bodies (Joint Working) (Scotland) Act 9 People are supported to live well at home or in the community for as much time as they can and have a positive experience of health and social care when they need it All adult care groups +/- children’s services & criminal justice Principles for integrated health and social care Strategic and locality planning based on population needs Integrated governance : body corporate or lead agency Integrated budgets for health and social care Nine national outcomes for health and wellbeing Chief accountable officer has integrated oversight of delivery

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 10

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Lead Agency model

Integrated Resources - Minimum to be delegated

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Health and Wellbeing Outcomes 13

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 2020 Vision for Quality 14 Everyone is able to live longer healthier lives at home or in a homely setting. Integrated health and social care, with a focus on prevention, anticipatory care and supported self management. Care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions. When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm. There will be a focus on ensuring that people get back to their home or community as soon as appropriate, with minimal risk of readmission.

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Policy Alignment

Getting to the Third Curve Time Performance Improvement Co-production, and personal Outcomes “In the next five years, let us ensure that Scotland is a person-centred country in the delivery of care and support to all citizens”. Deputy FM March 2015

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 17 From Personal to National Outcomes Source: Talking Points - Personal Outcomes Approach ( Points - Personal Outcomes Approach

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Improvement Network 18 A cross sector collaborative to support innovation and test and spread actions which collectively improve outcomes through:  WebEx virtual meetings and e-bulletins  Web portal to share good practice, evidence and resources  Digital stories and learning from the experience of people  Training in use of improvement methodologies  Synergy with Communities of Practice and networks  Use of measurement for improvement and benchmarking  Planning for sustainability  Support for coproduction and outcomes-based approaches

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors A Theory of Change 19 Source: A Stitch in TimeA Stitch in Time

Anticipatory Care Plan and Key Information Summary Shared electronic summary Available 24/7 across Scotland in multiple care settings Demographics Medication Information Allergies and Adverse Reactions Next of Kin and Carer Details Agencies Involved Important Medical History Homecare Support Treatment ceilings Resuscitation wishes

Innovation in General Practice: House of Care

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Intermediate Care Rapid Response / Early Supported Discharge Reablement Homecare Step Up / Step Down community beds Hospital at Home

Supported at Home 76% are managed in their own home instead of Hospital by the ASSET team 2,864 Patients accepted by ASSET in 29 Months 5.6 / Day 5.7 days Length of Stay 76% Beds Closed 50 Value £2Million+ North Lanarkshire

Building effective relationships and creating local integrated networks of care and support

Technology Enabled Primary Care - Right First Time, All the Time

Peer support and web based information and advice to help people manage their conditions

Community Connectors and Third Sector Partnerships

39% CHANGE FUND SPEND 2014/15 SUPPORTED CARERS 2 Million MORE DAYS IN OWN HOME THAN ‘EXPECTED’ 17% FEWER OLDER PEOPLE CONVEYED to HOSPITAL after a fall (non-injured) 10% REDUCTION IN RATE OF 75+ EMERGENCY BEDDAYS OVER 4 YEARS 1300 PER DAY FEWER PEOPLE AGED 65+ IN HOSPITAL BEDS THAN ‘EXPECTED’ IN RECEIPT OF FORMAL CARE AT HOME HAVE TELECARE 4000 PER DAY FEWER PEOPLE IN CARE HOMES THAN ‘EXPECTED’ 19% FEWER PEOPLE DELAYED IN HOSPITAL OVER 2 WEEKS

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Continuing Support to Build trusting relationships Build on the learning and progress from Reshaping Care Continue to spread innovation and good practice Develop locality arrangements and community resilience Adopt personal outcomes approaches and co-production Share health and care data for planning and performance Understand the contribution of prevention Evaluate economic impact of complex interventions Plan for disinvestments and to shift the balance of care

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Strategic Commissioning Improvement programme and elearning tools 30

Leadership at all levels ‘ ’It requires vision, initiative, patience, respect, persistence, courage, and faith to be a Transforming leader.” S Covey Councillor Peter Johnston, COSLA Health and Wellbeing spokesperson, called for a ‘permanent revolution’ of Scotland’s public services. March 2015

working seamlessly with colleagues in NHSScotland and partners who provide care making more and better use of technology and facilities to increase access to services strengthening workforce planning to ensure the right people, in the right numbers, are in the right place, at the right time putting new and extended roles into practice Integrated Interdisciplinary Care and Support

Integration people-change-fund-building-on-progress-june-2015/ Integration people-change-fund-building-on-progress-june-2015/ 34 JIT is a strategic improvement partnership between the Scottish Government, NHS Scotland, CoSLA, the Third Sector, the Independent Sector and the Housing Sector