Att18 SCCGb GB 04.06.14 Joint Strategy for Health

Sutton CCG & LB Sutton Partnership
Presenting our joint health and social care strategy for Sutton
Sutton CCG and LB Sutton have come together to develop and
deliver a joint strategy
Sutton CCG became the statutory organisation responsible for commissioning health services for
residents of Sutton in April 2013
LB Sutton has a statutory responsibility to commission social care services for local residents.
Sutton CCG and LB Sutton have come together to develop a joint strategy and this presentation sets out
the following:
Our joint vision to reshape health, social care and wellbeing services
The aim for our joint Strategy for Health and Social Care
Our four key objectives
Our five priority areas
Where we will be in 2016/17
Our governance structure moving forward
The demand and challenges to our services
There are 27 GP
Practices, and the
majority of unplanned and
planned hospital
admissions and care occur
at St Helier Hospital and St
George’s Hospital
St George’s
St Helier
Sutton’s A&E demand has
remained stable for the
past 3 years
Non-elective admissions for
people aged 75 years and
over, is much higher than
across other age groups at
Sutton has a population of
approximately 192,000, of which:
• Population over the age of 65 is
expected to increase by 18.7%
between 2011 and 2021
• 79% of are white and 12% from
Asian or Asian British ethnic groups
Jubilee Health Centre
Non-elective admissions have
increased by 3%,with spend
increasing by 14% in the past 3
Older people currently make up
73% of adults with eligible social
care needs.
A new community service model for Sutton
Resulting from the demand and financial challenge, and in order to achieve a sustainable
health and social care system fit for the future, service models in Sutton will need to adapt.
Co-commissioning between Sutton CCG and Sutton LB will be the mainstay of our Joint
Strategy for Health and Social Care and commissioning intentions
Co-commissioning efforts will be reinforced through the Better Care Fund
The Better Care Fund (BCF) is recognised as a national enabler for integrated care. A joint
pooled fund between Sutton CCG and LB Sutton will be created In Sutton, the minimum
transfer from Sutton CCG to the BCF will amount to £614k in 2014/15, increasing to £14m
in 2015/16.
Our vision for joint health and social care in Sutton focusses on
Re-shaping health, social
care and wellbeing services
so that people are
supported to remain well
for longer in their own
This will involve a step change in the way
that we plan care, from focussing on
reactively providing services when people
fall ill, to creating a balance and
proactively supporting people to stay
By 2016, we will provide services that deliver high quality,
integrated care to our residents
We will support our residents to remain as independent as they can for as
long as they can. We will support and educate our residents to self-care where
possible and we will prevent avoidable admissions to hospital providing
alternative and responsive community services. We will encourage
independent community-based living through joined up services and
professionals working closely together. There will be strong relationships
between commissioners and provider organisations so that we can realise our
Why do we need a joint health and social care strategy in Sutton
Our joint strategy will:
We therefore aim to meet the following
reductions in demand:
• build capacity in the community to work
collaboratively through integrated services
• build capacity in the community to identify
people at risk
• expand the capacity of the reablement and
rehabilitation services
Reduction in A&E
Avoidable NEL admissions
• realign the acute sector to match changing
demands and community capacity
• maximise people’s capacity to self-care
• plan and develop a community workforce in
collaboration with providers
• provide stronger links with voluntary services
and other community groups
Reduction in hospital-based
outpatient appointments
Reduction in outpatient
We have four main object
Supporting people to maintain
their independence
Helping people to remain healthy by stopping
them becoming unwell or preventing their
condition exacerbating, avoiding unnecessary
admission to hospitals or care homes
Providing more support in communities to help
people effectively manage their own health and
Reducing admissions and lengths
of stay in acute hospitals
Providing alternatives to admission then
improving discharge and building more effective
reablement to ensure maximum patient
Improving quality of care
Following an episode of ill-health or crisis with the
delivery of the right services, in the right place and
at the right time
Our schemes are organised into five priority areas
Long term conditions – as population over the age of 65 in Sutton grows, the number of people living with
one or more long term conditions will increase. Focus on identifying people with LTCs and assisting with
management and prevention
Planned Care – focus on ensuring that the right services are available to people in settings close to their
Older People – care for older people in Sutton will be provided as part of an integrated Older Patients
Providing Services Closer to Home – expansion of community-based care to ensure more services are
provided closer to home
Urgent Care – redirecting people with urgent needs away from acute services to community-based services
where secondary care is not required
Long term conditions
•Proactive approach to identify people with multiple LTCs and focus on management
and prevention
•Reactive approach to ensure responsive services , professionals and expertise are in
place to respond
•Identify people at greater risk of unplanned hospital admission and support through
active case management
•Move away from a historic disease pathway focus towards a more integrated
Planned care
•Expand the range of services which deliver community and specialist planned care
•Providing services in convenient services, close to where people live
•Support the continued relocation of services into the Jubilee Health Centre
•Improved referral management to ensure appropriate planned care is delivered in
the community
Older People
•As part of an integrated Older Patients Pathway provide improved quality of care to
all people over the age of 65
•Further develop in-reach/out-reach from community and social services to provide
better continuity of care and discharge planning
•Embed care planning and a person-centred approach delivered by a team of key
professionals who are connected with GPs and specialists
•Improve discharge planning and provide expanded services which promote timely
discharge and intensive community-based care to improve functionality,
independence and prevent readmission
Providing services closer to home
•Develop community estates where people can experience community care,
diagnostics and selected specialist care co-located on one site
•Improve care and responsiveness for people who are discharged from hospital,
including improving functionality, preventing social exclusion, supporting access and
signposting to alternative services
•Provide intense and timely access to intermediate care and rehabilitation
•Support, respite and education to informal carers and family members
Urgent care
• Services schemes which provide responsive urgent care and rapid response interventions
• A whole-system model which encourages prevention of admission and offers signposting
including Out of Hours and 111 services
• Co-located in the emergency department is our Rapid response multidisciplinary team
• Facilitating the implementation and development Ambulatory Care Service
Delivery Plans to support our strategic aims and objectives
We have developed delivery plans for each of the priority areas outlining the key steps
required in 2014/15 and 2015/16 in order to implement the individual schemes within each
area. Commissioning managers from Sutton CCG and LB Sutton have outlined key milestones
for in order implement new schemes and further evaluate and manage schemes over the
next two years. The plans also outline the predicted outcomes that will be realised through
execution of the schemes
Our governance structure moving forward
Reorganisation of our governance will be required in order to deliver our aims and objectives. The
revised governance arrangements will be live from June 14.
Health and Wellbeing
One Sutton Commissioning
Transformation Programme
Long Term
Planned Care
Older People
Urgent Care
Prov. Services
In summary our joint health and social care strategic plan will
help us to deliver…
A whole-system service model which expands community-based health and social care, and
improves the connections between primary care, third sector services and acute services
A proactive set of community-based services which are targeted at those who are at risk of
escalating needs, and which will help to keep people out of hospital, independent and
improves outcomes
A reactive set of community-based services which will be responsive for those people whose
needs rapidly escalate, preventing inappropriate time in hospital and improved communitybased rehabilitation and reablement
Shift and expansion of services which will bring high quality care and expertise closer to home
Strengthened relationships and governance between Sutton CCG and LB Sutton working in
partnership with community-based and acute care providers

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