Planned Care RSCH Planned care referrals on plan for first three months Referral support service Generic Referrals Totally Health Integrated Respiratory Pathway Cardiology Ophthalmology Direct Access Physiotherapy and Pathology

Unplanned Care Frailty Initiative – Initial monitoring reports will be received in October 14 – Frailty Forum has been established to provide practices with the opportunity to feedback about the initiative. The next meeting will take place on 25 September. Ambulatory Care Unit and Frailty Service – Direct access to a geriatrician - ‘Geriatrician of the day’ bleep and contact details to be disseminated across practices in September – Interface geriatricians to attend primary care Frailty MDTs – piloting attendance at 4 practices in September to further understand the logistics and challenges of frail patients as well as to link in with the Frailty Initiative – Discussions on the development of a single point of access underway across providers Operational System Resilience Plan – Systems Resilience Group met on 20 August 2014 to approve the plan – Key workstreams: Extending community nursing into the evenings and weekends Supporting the development of virtual wards Preventative interventions with high risk groups - alcohol, COPD, Mental Health Raising awareness of NHS 111

Unplanned Care BCF Hospital Improvement Group – Meeting weekly in various venues (Milford Hospital, GP practices, Haslemere Hospital, Royal Surrey) to address challenges across providers – Virtual ward round undertaken in primary care, which has provided a useful forum for discussion between GPs, discharge coordinators and community matrons – Developing links with the voluntary sector (Age UK) to understand how these services can complement those currently available in the community Community Hospital RESET – Following feedback from the first RESET week, it has been agreed that a community RESET week will be run across the Milford, Haslemere and Farnham sites – This will take place in late October Acute Hospital RESET – Plans are beginning to run the second RESET – This will take place at the beginning of November

Medicines Management Polypharmacy medication reviews for patients not residing in a care home – Part 1 completed, 29 patients reviewed over 3 months, net saving of £8949 / £308 per patient – Part 2 due to commence November 14 to review 400 patients. Medications reviews for Care home patients – 1.6 WTE been appointed to undertake these medication reviews over the next 12 months. – To date 320/2000 patients have been reviewed. – Project documentation complete – Care home pharmacists to provide nutrition training to catering staff at care homes. “Food first” being promoted to support reducing the over reliance on ONS.

“Not dispensed scheme” reducing wasted medicines commenced April 14 6 pilot community pharmacies, Godalming area feeding back to practices on prescription items that the patient does not require that month. This project will be reviewed in October with a view to rolling it out across all 35 community pharmacies Alternative dressings procurement Community Nutrition Management Specialist – The CCG have agreed a 12 month which is due to commence late Autumn. The post is very much going to be an advisory / educational role, with the successful applicant undertaking the following: – Developing the Primary care ONS strategy whilst working with secondary care colleagues – up skilling primary care clinicians to manage, prescribe and review prescribing of ONS for their patients – Providing an advisory role to primary care clinicians Medicines Management

Mental Health and Learning Disability Review of adult mental health pathway in Guildford and Waverley: CCG working with SABP Trust. More pro-active relationship with IAPT providers. Proposal to take IAPT out of collaborative in 15/16. 15% IAPT target trend improving and forecast meet target by year end. Alcohol liaison service proposal for RSCH. Psychiatric Liaison Service at RSCH, CCG working with service to improve efficiency and respond to increasing non-elective MH activity. Commissioning LD services though collaborative and partnership board.

Children’s GP Reports to Child Protection Case Conferences. Potential quick and straightforward arrangement using secure and an agreed standard proforma Child and adolescent mental health services across Surrey are being review ahead of a retender exercise. We are still in an engagement phase until 30 th September and would welcome feedback from you either via our survey :

End of Life Care G&W End of Life steering group established to co- produce a whole system pathway to meet the needs of patients who are dying in a place of their choice Practices using PACe care planning documentation, quality audit under construction G&W PACE model selected as part of the Kent University Research Practice are working with the emergency service to establish the use of IBIS which will allow the PACe care plan to be attached and access as clinically appropriate