1. Poor citizen experience Pockets of excellence but often fragmented services Services not focused on independence and control Uneven access to quality primary and community services Unprecedented financial challenge NHS Local Govt Increasing demand Aging Population Medical innovation Poor population health Unsustainable models of care Episodic not long term care People in hospital and care institutions unnecessarily Unrealised citizen & community capacity 1.New models of primary and community services e.g. federated practices, improved access 2 Local Derived New Models of Integrated Health and Social Care (x10), Integrated Community based services End of life, 24/7 urgent response Self Care (e.g Personal budgets, Carers strategy) Technology, Supported housing Building community capacity (e.g. Care navigators), 3. Changing role of local hospital. Secondary care clinicians more aligned to primary care led integrated team working, and outreach Improved citizen experience People “in control and independent” Enhanced quality in acute services Greater focus on prevention. Large scale reduction in unplanned and avoidable admissions to hospital and care institutions Sustainable service models Wider Public Service Reform Context to reduce demand and sustain future economic growth WhyWhatSystem Ambition

2. The scope of work

3. Key principles Greater Manchester’s System Agreement 2013 “The future health and social care system will look substantially different and that improved quality of health care for Greater Manchester residents will underpin the following key principles of a new system:  People can expect services to support them to retain their independence and be in control of their lives, recognising the importance of family and community in supporting health and well being  People should expect improved access to GP and other primary care services  Where people need services provided in their home by a number of different agencies they should expect them to planned and delivered in a more joined up way.  When people need hospital services they should expect to receive outcomes delivered in accordance with best practice standards with quality and safety paramount – the right staff, doing the right things, at the right time.  Where possible we will bring more services closer to home (for example there are models of Christie led Cancer services delivered from local hospitals)  For a relatively small number of patients (for example those requiring specialist surgery) better outcomes depend on having a smaller number of bigger services.  Planning such services will take account of the sustainable transport needs of patients and carers.  This may change what services are provided in some local hospitals, but no hospital sites will close”

4. GM Integrated Care Programme This element of the programme is jointly led by each Clinical Commissioning Group (CCG) and Local Authority We have developed new GM Community Based Care, Hospital and Primary Care standards – included as part of the public conversation, engagement and consultation process on whole system reform during 2014. We continue to support all 10 localities models to overcome the challenges of integrated care implementation, including: Models of Contracting and Reimbursement Competition and Collaboration Workforce Information sharing and new technology deployment 10 models of integrated care were in shadow operation by 1 st April 2014 and in full operation, backed by the HM Treasury approved CBA by 1 st April 2015.

5. We have agreed common standards for community based care

7. Primary Care Strategy Multidisciplinary Care Identification of Long Term Conditions Best Care Pathways Medicines Optimisation Integrated Care Teams GP as co-ordinator of Care Involvement in Care Access to care records Promotion of self-care Primary prevention Patients die in place of their choosing Access and Responsiveness Digital Technology; range of access mediums Continuity of Care Increased access to primary care services Increased Out of Hospital Services Locally based enhanced services Smooth primary/secondary care interface Inter-practice referrals Quality & Safety

8. By the end of 2015, everyone living in Greater Manchester who needs medical help, will have same-day access to primary care services, supported by diagnostic tests, seven days a week; By the end of 2015, people with long term, complex or multiple conditions such as diabetes and heart disease will be cared for in the community where possible, supported by a care plan which they own; Community-based care will focus on joining up care with social care and hospitals, including the sharing of electronic records which residents will also have access to; and By the end of 2016, residents will be able to see how well GP practices perform against local and national measurements. Primary Care Standards – Healthier Together

9. Primary Care Strategy approved January 2014 Launched 6 primary care ‘Demonstrator’ sites - testing elements of the primary care strategy including extended access, multidisciplinary care, end of life care and extended care homes support (independent evaluation available on request) Primary care was at the heart of the Healthier Together consultation, with 4 primary care standards included, representing a statement of intent to the people of Greater Manchester The 4 th Greater Manchester Primary Care Summit was held, with attendance from over 300 health and social care professionals Transforming Primary Care

10. Success in waves 1 and 2 of the Prime Ministers Challenge Fund, with a wave 1 site in Bury and 2 wave 2 sites in the City of Manchester & Wigan Borough. These programmes have secured investment of over £11m into the development of new models of service delivery On behalf of CCGs in Greater Manchester: – Greater Manchester Primary Care Medical Standards to reduce unwarranted variation in quality and care – Greater Manchester IM&T Strategic Vision – Strategic visioning for public sector estates – Best practice guidance for patient access to records – Organisational development for GP federations Transforming Primary Care

11. The characteristics of our current models 11 The main causes of Greater Manchester's high cost/poor outcomes are: ‘Too late care’ where conditions are either not prevented or detected early enough, nor treated to evidenced based standards, and patients' needs escalate resulting in preventable hospital based emergency and elective care and for longer than is necessary. The perverse incentives and associated self-interested organisational behaviours of Greater Manchester's hospitals, and weak and uncoordinated system management A population that is "inactivated". That is too many of our population don't know that better health outcomes are significantly driven by appropriate lifestyle choices, self-care, the health benefits of work and the potential of a prevention driven NHS and Social Care service.

12. What does radical reform look like? 12 Shifting the balance of investment towards proactive, early help and away from a crisis response Health & care defined by an approach based on prevention Intelligence led, highly targeted preventative action based on a deep knowledge of our communities and their strengths More integrated public services responding to all forms of vulnerability Increased healthy life expectancy Wanless for GM 2022… “Levels of public engagement in relation to their health are high. Life expectancy increases go beyond current forecasts, health status improves dramatically and people are confident in the health system and demand high quality care. The health service is responsive with high rates of technology uptake, particularly in relation to disease prevention. Use of resources is more efficient.”

13. Devolution is the mechanism, not the master… 13 What is the problem we are trying to solve…? ….devolution can be the trigger for greater and necessary positive reform A growing ageing population Poorer health & growth in chronic conditions Instability & fragmentation in the health & care system Consequences Unplanned, Haphazard change Poorer care and treatment Difficulty in meeting future health needs Failing the health & care workforce Consequences Unplanned, Haphazard change Poorer care and treatment Difficulty in meeting future health needs Failing the health & care workforce Increasing pressure on health & social care

14. Greater Manchester local health profile is significantly worse than England Average SOURCE: 2014 Local Health Profiles, AHPO BetterMixedGenerally worse General health Lower than averageHigher than average Deprivation Comparison to England average Local Authority Trafford Wigan Tameside Stockport Salford Oldharn Manchester Bury Bolton Children living in poverty Life expectancy gap. most and least deprived areas Life expectancy Deprivation Year 6 children classed as obese General health Rochdale 11,900Lower for men and women 20.7% 9.7 years lower for men. 7.9 years lower for women 6,500Higher for women18.4% 10.1 years lower for men. 6.3 years lower for women 12,000Lower for men and women 18.9 % 9.4 years lower for men. 8.5 years lower for women 10,300Lower for men and women 18.6% 10.9 years lower for men. 8.2 years lower for women 8,500Similar for men and women 17.1 % 10.8 years lower for men. 8.4 years lower for women 12,700Lower for men and women 21.5 % 11.5 years lower for men. 8.2 years lower for women 13,300Lower for men and women 19.3% 11.2 years lower for men 9.2 years lower for women 34,630Lower for men and women 24.7% 9.6 years lower for men. 8.2 years lower for women 6,670Lower for men and women 19.3 % 11.5 years lower for men. 7.6 years lower for women 13,040Lower for men and women 20.0 % 12.1 years lower for men. 9.2 years lower for women

15. This isn’t just about Health 15 The roots of poor health are found across society and the public service – we need to do more than just respond at the point of crisis. This requires integration of not just health and care, but contributing wider public services

16. GM Devolution – the background Greater Manchester Devolution Agreement settled with Government in November 2014, building on GM Strategy development. Powers over areas such as transport, planning and housing – and a new elected mayor. Ambition for £22 billion handed to GM. MOU Health and Social Care devolution signed February 2015: NHS England plus the 10 GM councils, 12 Clinical Commissioning Groups and NHS and Foundation Trusts MoU covers acute care, primary care, community services, mental health services, social care and public health. To take control of estimated budget of £6 billion each year from April 2016.

17. Vision To ensure the greatest and fastest possible improvement to the health and wellbeing of the 2.8 million citizens of Greater Manchester

18. Objectives  To improve the health and wellbeing of all of the residents of Greater Manchester (GM) from early age to the elderly, recognising that this will only be achieved with a focus on prevention of ill health and the promotion of wellbeing. We want to move from having some of the worst health outcomes to having some of the best;  To close the health inequalities gap within GM and between GM and the rest of the UK faster;  To deliver effective integrated health and social care across GM;  To continue to redress the balance of care to move it closer to home where possible;  To strengthen the focus on wellbeing, including greater focus on prevention and public health;  To contribute to growth and to connect people to growth, e.g. supporting employment and early years services; and  To forge a partnership between the NHS, social care, universities and science and knowledge industries for the benefit of the population.

19. Benefits Enable us to have a bigger impact, more quickly, on the health, wealth and wellbeing of GM people Be more free to respond to what local people want - using their experience and expertise to help change the way we spend the money Create more formal collaboration and joint decision making across the region to co-ordinate services to tackle some of the major health, housing, work and other challenges - supporting physical, mental and social wellbeing

20. 20 DMT contact: Alex Heritage Strategic Plan (Clinical & Financial Sustainability) DMT contact: Alex Heritage Strategic Plan (Clinical & Financial Sustainability) Health & Social Care Devolution Programme DMT contact: Liz Treacy Establishing Leadership, Governance & Accountability DMT contact: Liz Treacy Establishing Leadership, Governance & Accountability DMT contact: Sarah Senior Devolving Responsibilities and Resources DMT contact: Sarah Senior Devolving Responsibilities and Resources DMT contact: Warren Heppolette Partnerships, Engagement and Communications DMT contact: Warren Heppolette Partnerships, Engagement and Communications DMT contact: Leila Williams Early Implementation Priorities DMT contact: Leila Williams Early Implementation Priorities 7 Day Access to Primary Care Public Health place-based agreement major programmes and early intervention priorities Academic Health Science System Healthier Together Decision Dementia Pilot Mental Health and Work Governance Legislative and Accountability Framework Workforce Policy Alignment The GM plan contains the following chapters: Strategic Plan Locality and Sector Plans GM Transformation Proposals and Financial Plan and Enablers It is recognised that a large proportion of the other programme areas will feed in to the Strategic Plan at the appropriate point, highlighted to the right The GM plan contains the following chapters: Strategic Plan Locality and Sector Plans GM Transformation Proposals and Financial Plan and Enablers It is recognised that a large proportion of the other programme areas will feed in to the Strategic Plan at the appropriate point, highlighted to the right Resources and Finance Primary Care Transfer Specialised Services Transfer Prevention, Self Care and Public Health (Single Unified Public Health System) Enablers (Workforce Training, Development and transformation, Capital and Estates) CAMHS Programme approach Programme Area Workstreams Patient, Carer & Public Engagement Change Movement OD and Leadership Development Support Services Strategy Support to Challenged Trusts Decision Making Mechanisms Additional work that feeds the strategic plan Other areas of work Key chapters of the strategic plan Communications and Stakeholder Engagement

21. Spring 2015 Summer 2015 Autumn 2015 Winter 2015 Spring 2016 Summer 2016 Autumn 2016 Winter 2016 Spring 2017 APRIL: Process for establishment Of Shadow Governance Arrangements Agreed and initiated AUGUST: Production of an Outline Plan to support the CSR process which will Include a specific investment fund proposal to further support primary and community care and will be the first stage of the development of the full Strategic Plan. DECEMBER: Production of the final agreed GM Strategic Sustainability Plan and individual Locality Plans ready for the start of the 2016/17 financial year DECEMBER: In preparation for devolution, GM and NHSE will have approved the details on the funds to be devolved and supporting governance, and local authorities and CCGs will have formally agreed the integrated health and social care arrangements. APRIL: Full devolution of agreed budgets, with the preferred governance arrangements and underpinning GM and locality S75 agreements in place. Timeline to Devolution MAY-DECEMBER: Announcement of Early implementation Priorities OCTOBER: Shadow arrangements in place and start for budgets, governance and accountability

22. Skills/ Behaviours needed Organisation first is not the approach we are seeking – we need ‘place’ leaders – Best interests of population – Willingness to pool or potentially cede autonomy Build relationships – Emotional intelligence – Build trust - speaking honestly, professionally Distributed leadership only approach – Clarity on who responsible for what, when – Communication – Everybody sees building ownership as their job 22

23. What this means for the GM Workforce: GM aspires to a future workforce that: Can recognise the wider determinants of health, are the source of demand for public services (e.g. worklessness, skills deficit, domestic abuse). Can adopt a perspective on residents as people living in their communities with hope and ambition. Are able to support individuals to achieve their personal goals and be active participants in managing their own care. Is able to adopt an asset based approach to talking with residents about how they want to live their lives, to reach their potential - rather than their needs and deficits. Feels liberated (through a positive approach that liberates staff talents and expertise) to be able to work in a truly integrated way to do the right thing for people in their communities. Is flexible, with core, common competencies to work across the spectrum of caring (and on to professional roles).

24. Any Questions?