AN INTRODUCTION TO STOCKPORT’S

HEALTH AND SOCIAL CARE

TRANSFORMATION PROGRAMME

[CITIZENS REPRESENTATION PANEL]8TH OCTOBER 2015

Introductions

Tim Ryley

Director of Planning and Corporate

A partnership…

The background

• Why do we need to change?People live approximately 11 years longer in the least deprived areas of Stockport compared to the most deprived areas.

Difference in years of lifeMost deprived quintile

Least deprived quintile

MALE

12.8 years

FEMALE

9.7 years

Other factors

• Thirty per cent of the Stockport population (or 80,000) have one or more long term condition

• The current system is not meeting the expectations and requirements of people with complex needs – i.e. those most likely to have problems with co-ordination of care and delays in transitions between services

• The prevalence of the major disease groups is increasing year on year.

Nationally people with long-term conditions account for:• Half of all GP appointments (this

equals 520,000 for Stockport GP Practices)

• Seven out of every 10 medical hospital beds (this equates to between 250 and 275 beds in Stockport NHS Foundation Trust)

• £7 of every £10 spend on health and care in England. Taking 70% of Stockport’s total Health and Social Care Commissioning budget of equals £302m.

Major disease prevalence

Smoking

Hypertension

Depression

Obesity

Asthma

Diabetes

Coronary Heart Disease

Chronic Kidney Disease

Stroke and TIA

Cancer

17.0%

14.1%

10.9%

8.5%

6.5%

4.5%

4.0%

2.8%

2.0%

1.9%

16.5%

13.8%

8.8%

8.2%

6.4%

3.8%

4.2%

2.2%

1.9%

1.2%

2008

2012

What this means for Stockport

• Health and social care will be subject to increasing demand from an ageing population

• Combined with a financial position that isn’t going to increase in line with this demand

• Fundamental changes have to be made to ensure that the people of Stockport continue to receive the highest quality care in the most appropriate environment.

Work to date

• Stockport Together Health and Social Care Congress in January

• Vision Decision agreed by all partner organisations

• Designated Portfolio Office established • Design phase and public/staff

engagement activity underway

Four programmesProactive Care: Delivering person-centred care within a community setting.

Empowering individuals to support themselves with input from health and social care providers.

Working together to maximise peoples’ independence in order to shift the balance from reactive to proactive care.

Prevention and Empowerment: Helping people to improve their own well-being.

Encouraging and supporting all staff to deliver positive health messages.

Embedding prevention and lifestyle advice in all health and social care.

Tackling the lifestyle choices which impact on an individual’s health.

Planned Care: Working with people who have an existing health or social care need and require on-going access to services.

Reducing unnecessary outpatient attendances and GP referrals by working to better understand patient needs.

Maximising the use of technology to improve patient experience.

Urgent Care: Providing access to people needing urgent, same-day care.

Improving the way people who require urgent access to care are assessed, stabilised and discharged.

Helping to stabilise people as soon as possible and to improve their experience and outcomes.

Stockport Together vanguard

11

The MCP model in Stockport is a GP led neighbourhood-based out-of hospital service, which includes community health services, mental health and social care and the third sector.Initially the MCP will be commissioned to deliver care to the over 65 population of Stockport on a weighted capitation basis. The Clinical Model covers:

Early Detection: The MCP will take responsibility for the early detection of disease through screening programmes Optimisation and Complex Management: People diagnosed must then be educated and activated to self-manage to the best of their ability. Crisis Response: Where people have complex conditions there will be an anticipatory plan to support them in the management of exacerbations themselves and reduce the stress that this can cause Planned Care: GPs will be able to call Consultants directly for advice initially across up to 8 specialties using a cascade systemCommunity Activation: utilising the skills of social care and third sector partners, MCP will build community capacity in each neighbourhood.

Stockport Family

Programme

Urgent Care(front end only)

initially for over 65s

Planned CareZone 4 – Specialist Services

including complex surgeryMaternity and Gynaecological

services

Vision for the Multispecialty Community Provider (MCP) Model (2016/17+)

Services for Children and Young People

NHS Services not commissioned by Stockport CCG

e.g. Ambulance Service, dentists, optometrists, pharmacists, walk-in

centres and NHS 111

Phase 1

Neighbourhood Services/Integrated Team

• GPs• MDT Manager• Social care team• Community Nurses• Voluntary sector

Cheadle & Bramhall going live (with extended hours) October ’15. Other neighbourhoods March ‘16.

Phase 2b

Borough-wide Support ServicesPotential services:

COPD, Heart Failure, Diabetes, Equipment,

Podiatry, Alcohol & Drug Abuse, Mental Health,

End of Life Care

Community not hospital-based

Phase 2a

Intermediate Tier Services• Home-based• Bed-based

To reduce number of patients admitted to hospital

and to facilitate hospital discharge

Community not hospital-based

Integrated Neighbourhood Services (INS) Proactive Care

Multispecialty Community Provider

Planned Care• Zone 1 – Self-help service (links with Prevention Programme)• Zone 2 – Primary Care services (links with INS)• Zone 3 – Primary Care with specialist advice , e.g. Consultant

Connect idea

Prevention & Empowerment• Find & Treat – early identification of risk

factors and diseases (links to INS)• Web-based self-help service

Outside Scope Potentially in-scope

Vision from a service user not service provider perspective. Users will see a move away from hospital-based services to greater focus on health education, self-help, and care from multidisciplinary teams at neighbourhood centres providing simpler, joined-up and more effective care pathways.

Note: subsequent diagrams/tables/narrative will show the provider/funder perspective outlining the proposed changes to funding and contracting.

What’s next?

• Move through the design phase and begin implementation across four programme areas

• Work with stakeholder groups to get buy-in at all levels and to help shape the planned activity

• Follow up workshops to shape the programme

Questions?

What will neighbourhoods do?

• Develop intermediate tier services within neighbourhoods and have clear links to borough wide intermediate care services

• Clearly define the access to specialist services and the relationship between the INS and borough wide services

What will neighbourhoods do?

• Provision of outpatient and acute outreach/shared care services at a neighbourhood level

• Development of medicines management model within the neighbourhood

Expectation

Reality

Lack of continuity, repeating tests and information

Paper, faxing, telephones and disconnected IT

What’s the impact on Quality & Safety?

Connect: Connecting infrastructure and communications

systems

Integrate: Integrating Records & Information about the person

Empower: Consistent, multi-channel public experience

Collaborate: Collective Health & Social Care Technology governance and delivery

Areas of work

Take Control

What will it mean for People

• Reduce duplication, people not repeating information

• Practitioners can access all relevant information about a person

• Find the at risk people using combined data

• Empowered people accessing and adding to their online records to take control

• Transactions with services are online• Teams can work together • Use apps and online content to find

local health & care services and information

Paul Fleming Associate Director IM&T Stockport CCG

@Healthiapps e: PaulFleming@NHS.net t: 0161 426 5915

Question

• How do we engage people in Stockport to use technology to better self-manage their conditions?

• What support is needed from practitioners to do this?

CITIZENS REPRESENTATION PANEL

9TH OCTOBER 2015

Why did we set this up?

• The scale of the transformation

• Strong challenge

• Ambassadors

National guidance tells us……..

• Accountable to the public, communities and patients

• Best proposals are developed through early and ongoing engagement

• Service change complex

• Partnership is key

Membership

• CCG patient panel• Foundation Trust Governors• Pennine Care Governors• Carers• Voluntary sector• Healthwatch• Councillors• GP Practice Patient groups

• Starting point – we need people that have some knowledge and interest

Seat at Integrated

Care board

Member of programme board

Member of

Citizens Representation Panel

Take part in specific design meetings

Signed up for 'Stockport Citizens' mailing list

Follow social media channels

Attend briefings or engagement meetings

Take part in co-production events

Take part in surveys

Read materials or articles

Levels of involvement

Role

• Make any recommendations on key elements of the planning and design

• Provide scrutiny on our communications and public engagement– Communities involved as partners?– Enough time spent describing case for change?

• Encourage interest and involvement from other members of the community

• Spread the word!

Expectations

• To attend and contribute at panel meetings

• Read any required papers ahead of the meeting

• Keep up to speed with information we send out

• Respond to email requests for information

• Never use the forum to pursue a personal agenda

• Be respectful of each other and individual opinions

Chair role

• Seat on Integrated Care Board – final decision making body

• Seat on Enabler Group

• Preparation ahead of meeting

• Role description issued next week• Payment????

Comms and engagement activity

• Series of introductory sessions with local Stockport Groups

• More coming up:– Dementia Awareness: Offerton – Saturday 10th

October– World Stroke Day: Heaton – Friday 30th October– Other local groups

Comms and engagement activity

• Experience-Led Commissioning Workshops

Comms and engagement activity

• Website launched• Twitter profile established• Advertising in local press

Communications & engagement strategy

Tell us what you think……………………..

• Objectives• Target audiences• Key messages• Insight so far• Channels• Comments please……