1. Developing Accountable Care in Swindon

2. What are the problems in Swindon?
An increasing number of people living with complex long-term conditions.
A population with a growing number of older people.
Difficulty in recruiting GPs and nurses- impact on sustainability and resilience of practices.
Rising demand for same day / urgent care services
Limited clinical linkages between primary and secondary care
Significant areas of new housing developments within the town and the New Eastern Villages
Care homes feel unsupported- easier to dial 999/ request admission
Social care demand exceeding budgets
Demand for inpatient care exceeding supply.
Population and demand rising faster than resources.

3. What local people told us
Help me to better manage my condition
We need more information about local services
Care should be more coordinated
I keep having to repeat my medical history
Help people to keep well
We need more community based services

4. The position in Swindon
Work is now underway in our communities across Swindon and Shrivenham to develop Accountable Care over the next two years because of the challenges we face.
We are in a unique position in terms of the relative “simplicity” of Swindon:
One Council (Swindon Borough Council)
One acute and community provider (Great Western Hospitals NHS Foundation Trust )
One CCG and primary care leadership (Swindon CCG and 25 GP practices)
Clearly defined mental health provider (AWP) and the voluntary sector

5. Team Swindon - delivering Accountable Care
Organisations will work together as a team, “Team Swindon”, making health and social care more streamlined and accessible for everyone. .

6. Our proposed draft model
Main point of contact for Health and Social Care:
First contact
Triage
Referral Management
Co-ordination of care
Urgent Care; 111
Telephone/Digital
Case Management
Acute Hospital
Physical Triage
Streaming
Diagnostics
Discharge
Complex care MDTs
Proactive management of complex cases
Community navigators
Primary Care access and contact
A&E Front door
Service delivery
Locality community services
Core and Enhanced Primary Care
IAPT
Intermediate Care Reablement
Mental health crisis
Community healthcare
Support for carers
Prevention and self care
Community bed based services
Residential and nursing homes
Step down beds
Supporting functions

7. Benefits to people
Increased amount of care for chronic disease delivered locally, with increased continuity of practitioner
Support for local communities to help themselves and get involved in priority setting and service development
Reduce the number of times people have to tell their story
Clinicians will have more time to discuss with individuals, how their long term condition affects them and they will be involved in the decisions regarding their care options
Healthcare staff will have more time for patients, to fully understand their care needs
Ensuring we can provide health & social care fit for the future
Helping people to stay well and out of hospital
Improved access to same day urgent care services through a single contact point
Experience improved care and easier transfer from hospital to home or home to hospital

8. What Benefits will People see?
Now
Uncoordinated care and spends lots of time in hospital.
Unsure where to get information on local services or how to best self-care.
Numerous appointments with different people.
Having to repeat her ‘story’
Betty is 83 and lives on her own
2019
Supported by a coordinated team of different professionals.
Able to get quick help from the right person without waiting for a GP appointment.
Better health and wellbeing with fewer trips to hospital.
Only telling her ‘story’ once.

9. Why do you need to know all this?
By getting your views on our plans we can ensure we are buying the best possible services to meet the needs of local people.
Your call to action
We want you to offer constructive challenge on the thoughts for the models of care.
We want you to tell us your experiences and/or ideas to help us re-shape healthcare and social care.
It is important to involve people like you, members of the public, carers and patient representative groups in what we do.

10. When will this happen?
We will be speaking to the public and clinicians during the next few months developing and refining the model for how integrated care can be delivered. We hope to agree some different ways of working next year such as multi-disciplinary team working closely with people with high intensity conditions.

11. Listening to you
(ask to speak to the Communications & Engagement Team)
@swindonccg
NHS Swindon CCG