1. Sasha Karakusevic

2. We have achieved substantial improvements for our community and receive positive feedback from patients and the public Both the Care Trust and Foundation Trust were finalists in the HSJ PCT/Acute Trust of the year in 2009 But we know we can and must do better

4. 1991 Whole district trust 1992-7GP fund-holding 2000Integrated Care Network plan 2005 Torbay Care Trust 2009Integrated Care Organisation pilot

5.  Partnerships  Innovation  Managing the system  Nurses and workforce  Diagnostics and decision support  24/7 versus local  Facilities, equipment and co-ordination

6. 1991 Working in Brixham 1995 Her mother needs a hip replacement, spends 2 weeks in Exeter having waited 12 months for surgery. Has a stroke 1 month later and spends 30 days in Torbay and 60 days at Paignton before discharge to a nursing home for 6 months. Dies. 2000 Retires. Husband has MI, waits for 3 weeks in hospital before transferring to London for surgery. 2008 Husband develops heart failure and dies 18 months later following 4 admissions

7.  Mother has hip replacement 3 months after seeing her GP. Date arranged to enable holiday with daughter pre-op. Enhanced recovery and VTE prophylaxis mean mum home 3 days post-op without complications.  Husband has chest pain. Calls 999 and has angioplasty 74 minutes later. Changes lifestyle.  Couple living happily and enjoying grandchildren.

8. 20092019Change Population140000160000+20000 Estimated non-elective admissions 3700044000+7000 Cash for non- elective admissions £67m +0 Cash per case£1825£1525-£300 No change! Add £13m £82 each Say £500 per family And this in only 25% of the health budget

9. Conditi on No. Condition NameNew Coding New Weigh t Old Weight 1 Acute myocardial infarction I21, I22, I23, I252, I25851 2 Cerebral vascular accident G450, G451, G452, G454, G458, G459, G46, I60-I69 111 3 Congestive heart failure I50131 4 Connective tissue disorder M05, M060, M063, M069, M32, M332, M34, M353 41 5DementiaF00, F01, F02, F03, F051141 6Diabetes E101, E105, E106, E108, E109, E111, E115, E116, E118, E119, E131, E131, E136, E138, E139, E141, E145, E146, E148, E149 31 7Liver diseaseK702, K703, K717, K73, K7481 8Peptic ulcerK25, K26, K27, K2891 9 Peripheral vascular disease I71, I739, I790, R02, Z958, Z95961 10Pulmonary diseaseJ40-J47, J60-J6741 11CancerC00-C76, C80-C9782 12 Diabetes complications E102, E103, E104, E107, E112, E113, E114, E117, E132, E133, E134, E137, E142, E143, E144, E147 2 13ParaplegiaG041, G81, G820, G821, G82212 14Renal disease I12, I13, N01, N03, N052-N056, N072- N074, N18, N19, N25 102 15Metastatic cancerC77, C78, C79143 16Severe liver diseaseK721, K729, K766, K767183 17HIVB20, B21, B22, B23, B2426 10-19 20-49

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11. b. 1928, lives forever

12. Excite, delight, simplify

18. Preventative Actions taken to avoid onset of known conditions Immediate Intervention Services in community which prevent admission to acute Acute Safe and efficient management of condition during acute intervention Reablement Services provided to maximise independence following acute admission or crisis Palliative Providing high quality care during end of life and enabling patients to die in place of choice Virtual Pooled Budget for Older Peoples’ Care Assistive Technolog y to support COPD patients Emergency Care Practitioner s supporting falls RACE Clinics Primary & secondary care Medical Model Emergency Admission to Hospital for complex conditions Hospital Discharge Co- ordinators Community Hospitals Medical Evaluation Orthopaedic Pathway COPD/CCF /Dementia in Nursing Homes End of life care Training

19.  Self care when possible  Tele-health support for high risk periods  Packages of care optimised to maximise benefits  Pro-active intervention when markers indicate increasing risk

20.  Investments to optimise capacity of local care settings and teams  Efficient support to optimise decision making and promote flexibility  Real time feedback of results and alerts accelerates improvement in outcomes  Virtual activity  Specialists support frontline teams

21. 2020 Getting more frail and forgetful. Husband has diabetes and some heart failure. Daughters live in London and Scotland Local support network in place (based in local nursing facility) to respond to issues detected by home monitoring system. Mr Smith has not needed to visit practice or hospital due to real-time monitoring and medication management system. Daughters can support care through video link and access to shared records