1. The Third Horizon Dumfries Health and Social Care Hub

2. Imagine a world where… People always receive high quality, person centred compassionate care/support whoever provides it. Support is always provided by the right person or service at the right level and at the right time. End of life choices are explored and supported. Many fewer people need to go into hospital and if they do they can come home as quickly as possible, and The service model is financially secure.

3. The second horizon Test –how transparent system and processes can be developed –ways to ensure totality of resource is maximised and care packages are appropriate to level of dependency –do the above make a difference? Explore –how trust and seamless communication can be achieved –the support that can be provided by the Third Sector Answer –how can we adopt anticipatory care planning / early intervention / preventative approaches across the services? –does a personalised approach support sustainability? –what does it take for care to becomes seamless using an integrated approach?

4. Progress to date – co-locating the team Treasury Building –Agreement to co-locate Social Work, DNs, and STARS. –Building works due for completion end March 13 Recruitment –Complete Health and Social Work leads in post –Currently underway Joint OT Third Sector partner (agency appointed in Jan 13)

5. Progress to date - seamless communication Building relationships –Regular workshops have been running since March 12 –Weekly service user meetings in place since Aug 12 Receiving referrals –SCI- gateway referral draft document tested in emailable copy – electronic referral template now in development –Small numbers of non–urgent referrals are being managed by the health and social work care leads

6. Progress to date – transparent systems and processes Sharing information –SASPI information protocols in development to support the following: Access to MIDIS for named social work leads Access to Frameworki for named health leads Full involvement of our WRVS partner in case discussions Developing MIDIS Hub environment Receiving referrals –Access to SCI Gateway referral centre for named social work leads (exploring with Council SCI gateway referral for all GP – SW referrals across D&G)

7. Progress to date – seamless care Identifying opportunity for change –Process mapping undertaken to identify all areas of “waste” –Programme of work-shadowing underway to allow individuals to understand the impact on the whole system of their actions Developing change capacity –Training in PDSA methodology underway –Leads trained in Sliding Doors methodology