1. Inspiring Communities Together
Bernadette Elder –
Inspiring Communities Together

2. Inspiring Communities Together
Neighbourhood based charity
Membership led – Trustees elected through membership
Delivers activity – learning and volunteering
Facilitates – bring people together through two local forums
Advocate – link between agencies and local community
Securing resources – paid work linked to aims
Integrated Care – Community Asset theme lead

3. Strategic Context Salford care economy Salford Together Partnership
Urban area in Greater Manchester
Population of circa 230,000
Area of significant deprivation and health inequalities
Largely co-terminus
- Salford CGG (health commissioner)
- Salford Royal (acute and community healthcare provider)
- Salford City Council (adult social care)
- Greater Manchester West (mental health provider)
Long history of successful partnership working
Salford Together Partnership
Four high performing partners – within broader network of partners
£98M Pooled Budget - Integrated Care for Older People (ICP)
Governed by Alliance Contract
Underpinned by Service and Financial plan (inc. BCF)
Formal Programme Management approach (ICP)
ICP one of three major transformation initiatives
Out of hospital Care (primary care investment, renewal) & HT 3

4. The Start of this Journey…
Significant population
growth
High levels of need
Poor experience of care
Significant cost of care
Service duplication
National and international evidence
“Integrated health and social care for older people has demonstrated the potential to decrease hospital use, achieve high levels of patient satisfaction, and improve quality of life and physical functioning” Curry and Ham, Clinical and Service Integration – The Route to Improved Outcomes King’s Fund, 2010 4

5. Salford’s Integrated Care Programme1
Promoting independence for older people
Better health and social care outcomes
Improved experience for services users and carers
Reduced health and social care costs 3 2
Local community assets enable older people to remain independent, with greater confidence to manage their own care 1
Housing
Work
stream
Centre of Contact
acts as an central health and social care hub, supporting Multi Disciplinary Groups, helping people to navigate services and support mechanisms, and coordinating telecare monitoring 2
Multi Disciplinary Groups provide targeted support to older people who are most at risk and have a population focus on screening, primary prevention and signposting to community support 3

6. POPULATION STRATIFICATION
Wellbeing Plan
Sally’s standards
Able Sally 71%: c. 24,850
GP standards
Independence Plan
Needs Some Help 17%: c.6,000
Carer support and disease management
Supported
Independence
Plan
Needs More Help 9%: c.3100
Home care and intermediate care standards
Care Plan
Needs A Lot Of Help
3%: c.1050
Care Home standards
SHARED CARE PLANS
STANDARDS 6

7. 2020 targets – Emergency admissions and readmissions
19.7% reduction in NEL admissions (from 315 to 253 per 1000 ppn)
Reduce readmissions from baseline
Cash-ability will be effected by a variety of factors
Permanent admissions to residential and nursing care
26% reduction in care home admissions (from 946 to 699 per 100,000 ppn)
Savings directly cashable but need to be offset by cost of alternative care (especially increased domiciliary care)
Quality of Life, Managing own Condition, Satisfaction
Maintain or improve position in upper quartile for global measures
Use of a variety of individual reported outcome measures
Flu vaccine uptake for Older People
Increase flu uptake rate to 85% (from baseline of 77.2%)
Proportion of Older People that are able to die at home
Increase to 50% (from baseline of 41%)

8. Alliance Agreement Lead Commissioner BENEFITSP
BENEFITS
Full range of services within a single management arrangement – more effective, efficient and coordinated care
Collaborative environment without the need for new organisational forms
Aligns interests of commissioners and providers, removing organisational and professional ‘silos’ that contribute to fragmented and sub-optimal care
Collective ownership of opportunities and responsibilities; any ‘gain’ or ‘pain’ is linked to performance overall
Supports a focus on outcomes and incentivises better management of population demand
CCG, City Council, SRFT, GMW, Salix
Health, social care & wellbeing for population
£98m pooled budget
Some services subcontracted
Phased introduction 2014/15 onwards 8

9. Integrated Care -> ICO
Capitalise on our common purpose, strong relationships, and our success
Extend the vision:
Population Health Improvement beyond “out of hospital care”
Single system of governance for health and social care
Full population list
Strategic commitment to develop an ‘Integrated Care Organisation’ – initial focus on adults and older people 9

10. Realise the Vision… Objectives
Integrate commissioning
Single pooled budget across health and social care
Single strategic vision, robust governance & shared decision making
Pathway to single capitated budget
Create an Integrated Care Organisation
Prime provider model
SRFT Lead - direct provision of health and adult social care. Supply chain
Transform and Integrate Primary Care
Investment for renewal – workforce, larger footprint - critical mass, estate
Range of models to involve general practice as a partner
Transform Urgent and Intermediate Care
System redesign, optimal use of estate
Radical shift towards new technology and telemedicine
Preventative, planned care in community and residential settings
Highest quality, safest, most productive H&SC system in England
Shift away from institutional settings
Empowering, anticipatory model of care – delivered in or near the home 10

11. Benefits - Outcomes Population System level Staff
More personalised care – in or near the home
Significant reduction in avoidable admissions to hospital and care homes
Improved quality of life for users and carers
Significant increase in the ability of people to manage their own condition
System level
More resilience, flexible governance to target resource around fluctuating need
New relationship with the community – accountable in one place to shape the system to meet demand with better outcomes, improved experience and greater efficiency
Highest quality, safest, most productive health and social care system in England
Staff
Most attractive workplace in England
Reorganisation around the needs of the citizen
New roles and greater career development opportunities 11

12. Implementation Challenges
As a Vanguard Site, Salford is ready to meet the implementation challenges ahead
Where Salford can contribute straight away
Integrated Care Programme Management
Alliance Contract Management
Whole system quality improvement e.g. Haelo
Longitudinal evaluation with academic partners e.g. CLASSIC
Support Salford is interested in accessing
Implementation resource
Due Diligence – Legal Challenges
Liaison with National Bodies – Access to thought leadership e.g. General Practice
Contractual / Payment Systems – risk sharing
Extension of CLASSIC programme 12

13. Community Asset model
“Using the knowledge and life experiences of older people to make life better by listening to and valuing their views: making sure this influences services to be better in future by building on community strengths. This will keep older people in Salford healthy, happy and independent for longer”

14. Engagement
The Citizen Reference Group (CRG) This formal structure was established as part of the ICP programme. The group of local older people are supported through a development worker and meet monthly to look at aspects of the programme – acting as a critical friend. Members engage with areas of work which interest them and act as ambassadors for the programme by sharing key messages from the programme with their own networks.
The community asset work stream project group have engaged with older people through the network of partners who attend the monthly meetings (housing providers, development workers, third sector organisations, health workers and Salford City Council). Older people are invited to take part in workshops and focus groups to understand what is important to them to support their own health and well being.

15. Community asset work stream project group
Community asset model
An Age Friendly City – the commitment of the city to support older people to stay healthy and well.
Older Person Standards and Well Being Plans- the commitment by older people to support their own health and well being.
A set of tools developed by and for older people based in local neighbourhoods – the commitment of community and deliverers to support older people to stay healthy and well
Community asset work stream project group
The network includes a wide range of partners including mature people, City Council , University, Businesses, Charities, Social Enterprises, and Third Sector,
Work across a number of areas including housing, volunteering, befriending and Leisure and Health Improvement connections.
Matt – Martin to lead the session

16. Community asset approach
Ensure there is access to advice and guidance for older people to stay healthy and well and manage their own health and well being at a neighbourhood level with a focus on prevention and well being
Ensuring there is opportunity to access activity at a neighbourhood level and funding to support new activity
Developing technology as a tool for improved health and well being
Building volunteering as a life choice in older age and linking to the centre of contact and community connectors model
Joining up what is already happening

17. Cost and value to the NHS
Loneliness = £ to some one who smokes 15 cigarettes a day
Falls = over 4 million NHS bed days each year
14% (nearly 5000) of people aged 65 and over may be at risk of malnutrition (using BAPEN prevalence tool)
Bad oral health leads to poor levels of nutrition & can lead to social isolation
Technology can be a means to enable older people to renew and develop social contacts and engage actively in their communities.
Matt – Martin to lead the session

18. Barriers Improvement measures Community asset tools Reduce impact of
Prevention and well being
Oral health
Malnutrition
Step up
Tech and tea
Neighbourhood activity and fund
Volunteering
Community connectors
Well being plans
Social Isolation
Loneliness
Depression
Not eating well
Not engaged
Lack of access to information
Limited physical activity
Improvement measures
Barriers
Reduce impact of
Social isolation
depression loneliness
Reduce emergency admissions
Improved quality of life for users and carers
Increase the proportion of people that feel supported to manage own condition

19. CA budget 2015/16= £500,000
Asset mapping – development support to understand what we have and identify gaps and opportunities
Prevention and well being – Step up programme and advice and guidance including development of tools with older people
Neighbourhood activity - funding to support access to activity at a neighbourhood level and support new activity
Technology – tech and tea across the city as a tool for improved health and well being
Volunteering as a life choice in older age
Delivered by 3rd sector in the community
to support activity already being delivered

20. Meeting the targets Improvement measures:
Technology as a tool to increase the proportion of older people that feel able to manage their own long term condition and improve the quality of life for users and carers 
Prevention and well being activity ensuring there is access to activity, advice and guidance for older people to stay healthy and well and manage their own health and well being at a neighbourhood level with a focus on prevention and well being. This will help reduce emergency admissions and readmissions.
Neighbourhood activity ensuring there is opportunity to access activity at a neighbourhood level and funding to support new activity to increase the proportion of older people that feel able to manage their own long term condition and improve the quality of life for users and carers

21. Demonstrating the difference
Quality improvement:
A test and learn approach – Small scale test and rapid scale up based on evidence – dash board of measurers:
Loneliness tool
Well being plans
Digital skills
Increase in volunteers
increased community resilience
Improved level of fitness measurers
Increase in awareness of eating well in later life quiz
High level evaluation - CLASSIC:
Improved quality of life measurers

22. Moving from health to well being
Medical model
Hospital to home – Salford Home Safe
In own home –
Multi Disciplinary Groups (MDG)
Centre of Contact
GP Surgery
Asset based model
Building on individual strengths
Using the right tools – well being plan/Setting personal goals
Joining up what is already happening and flipping the axis to support the best outcomes for the person as safely and as quickly as possible
Matt – Martin to lead the session

23. Home support Hand holding Sign posting
Wellbeing
Plan
Medical support
Ready to manage own health
Home Safe
CA coordination group
Hospital
Home support
Confidence bld
Care on call
Health Trainers
Befriending
housing
Community assets
MDG
Hand holding
Centre of Contact
Well being coaches
Sign posting
GP surgery
Health Improvement
Neighbourhood management
Reconnecting individuals to the community

24. Opportunities and challenges
Community Asset approach recognised as part of the solution
Budget allocation – Lowest % at present
Starting to demonstrate impact = £££
VCS as partners in coproduction of model
Challenges:
Moving funding outside the system
VCS working in partnership – Salford approach 3SC (86 members)
Large contracts V small scale neighbourhood interventions
Matt – Martin to lead the session

25. Thank you for listening – For further information
Matt – Martin to lead the session