The Joint Strategy for Health and Social Care in Sutton · 1 Number taken from ‘Key Health Facts for Sutton 2012/13’, The Joint Strategy for Health and Social Care in Sutton (2014)

Executive Summary

NHS Sutton Clinical Commissioning Group | London Borough of Sutton

The Joint Strategy for Health and Social Care in Sutton

Enabling people to maintain their independence, health and wellbeing within their community

3/28/2014

The Joint Strategy for Health and Social Care in Sutton Executive Summary | Delivery Plan

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Executive Summary .............................................................................................................. 2

Context .............................................................................................................................. 2

Vision ................................................................................................................................ 4

Aims and Objectives .......................................................................................................... 7

Aims ............................................................................................................................... 7

Objectives ...................................................................................................................... 8

Priority Areas ................................................................................................................... 13

1) Long-Term Conditions ............................................................................................. 13

2) Planned Care ........................................................................................................... 17

3) Older People ............................................................................................................ 20

4) Providing Services Closer to Home .......................................................................... 24

5) Urgent Care ............................................................................................................. 28

Governance ..................................................................................................................... 32

Risks and Issues to Delivery ................................................................................................


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Executive Summary The following executive summary describes the Joint Strategy for Health and Social care for

Sutton. Sutton Clinical Commissioning Group (Sutton CCG) and the London Borough of

Sutton (LB Sutton) have come together in partnership to develop and deliver a joint strategy

which will enable people to maintain their independence, health and wellbeing within their

community. The co-commissioning efforts will be reinforced by strengthening organisational

relationships and a pooled budget; enabled by the Better Care Fund planning process. This

Executive Summary incorporates a Delivery Plan which will demonstrate ongoing progress

made to implement joint health and social care schemes across the borough of Sutton. The

schemes are in partnership with the LB Sutton where possible. Where schemes are

specifically health they reflect Suttons operating plan and strategic priorities.

Context

Sutton CCG became the statutory organisation responsible for commissioning health

services for residents of Sutton (LB Sutton) in April 2013. LB Sutton has the statutory

responsibility to commission social care services for its residents. There are recognised

inter-dependencies and overlaps between these services, so both Sutton CCG and LB

Sutton have been working together, through the One Sutton Commissioning Collaborative

(OSCC), to ensure services are increasingly coordinated.

Sutton has a population of approximately 192,0001, of which the working age (20-64 years)

population accounts for 60.8%, compared to 64.4% in London2. The population over the age

of 65 is expected to increase by 18.7%3 between 2011 and 2021, in line with the rest of

London.

Sutton has become more ethnically diverse over the last ten years; around 79% of people

living in Sutton are white, compared to nationally (85%) and London (60%) and 12% was

estimated to be from Asian or Asian British ethnic groups (compared to 18% in London)4. It

will be important to monitor diversity in Sutton on a regular basis to understand future trends

and potential pressures5.

Both men and women in Sutton have higher life expectancy than the national and regional

average6 and fewer people die from avoidable conditions7. However, Sutton does suffer from

health inequalities. An illustration of this is the eight year variance in life expectancy across

different parts of the borough, strongly correlated with deprivation8.

Sutton is served by 27 GP practices, and the majority of unplanned and planned hospital

admissions and care occur at St Helier Hospital (located within Sutton, part of Epsom and St

1 Number taken from ‘Key Health Facts for Sutton 2012/13’, The Joint Strategy for Health and Social

Care in Sutton (2014) 2 Sutton Joint Strategic Needs Assessment (2012) Available from:

http://www.suttonjsna.org.uk/index.html 3 Sutton Joint Strategic Needs Assessment (2012) Available from:

http://www.suttonjsna.org.uk/index.html 4 Sutton Joint Strategic Needs Assessment (2012) Available from:

http://www.suttonjsna.org.uk/index.html 5 Ibid.

6 Ibid.

7 Ibid.

8 2011 Census Sutton Health - https://www.sutton.gov.uk/CHttpHandler.ashx?id=21538&p=0


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Helier University Hospitals NHS Trust) and St George’s Hospital (located in Wandsworth). In

2012/13, Sutton CCG spent £18.7m on non-elective admissions for people over 65; of this

£14.2m was attributable to people over 75 years and £7.2m to people over 85 years9.

However, there are fewer admissions to residential and nursing homes compared to national

and regional rates. Sutton has additionally been successful in making Personal Budgets a

universal offer for all those eligible for social care support in the last 18 months.

Health and health-related services in Sutton were previously commissioned by Sutton and

Merton Primary Care Trust, which was abolished on 31st March 2013. The Primary Care

Trust was superseded by Sutton CCG and Merton CCG; however, the experience of

providing and commissioning joint services continues to have an impact today, in terms of

data, finances, and service provision. Some contracts, notably those with the community

services provider Sutton and Merton Community Services (SMCS, part of the Royal

Marsden NHS Foundation Trust), are still jointly held between Sutton CCG and Merton CCG.

Therefore a considerable degree of joint working and co-commissioning occurs between

both CCGs.

9 Figures taken from ‘Key Health Facts for Sutton 2012/13’, The Joint Strategy for Health and Social

Care in Sutton (2014)


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The following evidence demonstrates the demand and challenges to our services:

Resulting from the demand on all health and social care services, the financial challenge in

Sutton is significant, and in order to achieve a sustainable health and social care system fit

for the future, service models in Sutton will need to adapt. Recognising this, co-

commissioning between Sutton CCG and Sutton LB, working in partnership with providers

and with clinical and professional expert steer, will be the mainstay of our Joint Strategy for

Health and Social Care and commissioning intentions.

Vision

Our Joint Strategy for Health and Social Care in Sutton is focussed on re-shaping health,

social care and wellbeing services so that people are supported to remain well for longer in

their own homes, rather than becoming unwell and requiring hospital and residential and

nursing care support. 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

Sutton’s A&E demand has remained stable for the past 3 years (2011/12 to 2013/14 projected)

Non-elective admissions have increased by 3%, with spend increasing by 14% in the past 3 years (2011 to 2013)

Non-elective admissions for people aged 75years and over, is much higher than across other age groups at 9%, with an increase in spend of 20% (2011 to 2013)

In 2013/14 the top 20 highest spending residential and nursing care homes used ambulance conveyance and acute services costing £3.8million. The majority of the ambulance calls were during core hours where alternative services were available.

Older people currently make up 73% of adults with eligible social care needs.

In 2012/13 £18.4m was spent on care home placements, £8.5m on domiciliary care and direct payments, £8.3m on supported living, and £1.5m on reablement services

60% of those who complete reablement care with the specialist team do not require immediate ongoing care

Delayed transfers of care have historically been good with one per month on average, but recently have increased to 3 per month

Where acute hospital discharges require a social services assessment and discharge plan (usually within 48 hours) increased demand has historically peaked in the winter. In 2013/14 the high level of demand has been sustained throughout the year without winter variation

£708k is spent yearly on placement of equipment following occupational therapy assessments and this service and budget is under increasing pressure

Adult safeguarding cases and activity are increasing in Sutton following increased awareness. In comparison to 2005 where 50 cases were reported, in 2011/12, 2012/13 and 2013/14 rises from 919 to 1,148 and to over 1,200 were seen respectively


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proactively supporting people to stay healthy. We as co-commissioners, Sutton CCG and LB

Sutton, and in partnership with our community providers will deliver services in an integrated

way which enables patients to receive effective care closer to their homes.

Services will be person-centred and many schemes will be targeted at those groups

identified at most risk of hospital or care home admission, and those with multiple long term

conditions. Given the ageing population, the approach is especially relevant to older people;

nationally, people over the age of 65 unplanned admissions account for 68% of hospital

emergency bed days10. In addition, there is a range of risks associated with emergency

admission, such as increased dependence, reduced mobility and contracting a Hospital

Acquired Infection11. There are therefore clear advantages to avoiding hospital admission

from both the perspective of patient outcome and experience as well as reducing demand on

acute services. Furthermore, our Joint Strategy for Health and Social Care and our co-

commissioning approach will promote a universal offer to the residents of Sutton. We will

provide services which enable people to be proactive about their health and wellbeing, and

remain as independent for as long as possible. This will be a whole-system approach which

will also strengthen the relationships between services and professionals, including primary

care, third sector services and the other community organisations.

Therefore our vision is to create an integrated service model based on the following

principles:

The implementation of the Better Care Fund (BCF), recognised as a national enabler for

integrated care, will result in the creation of a joint pooled fund between Sutton CCG and LB

Sutton. In Sutton, the minimum transfer from Sutton CCG to the BCF will amount to £614k in

2014/15, increasing to £14m in 2015/16. In keeping with our vision for coordinated and

integrated services, we will ensure that these funds are used to maximum effect, which will

both improve quality of care for residents of Sutton and avoid any cost pressures resulting

from fragmented services. We have therefore created a vision for out of hospital health and

social care services in Sutton which reflect the joint ambitions for both Sutton CCG and LB

Sutton, and assist in addressing care needs for Sutton residents more holistically. Through

our integrated approach to commissioning services and working with our health, social care

and third sector providers, appropriate care will be provided 7 days a week seamlessly

without organisational and professional barriers.

10

Older people and emergency bed use: Exploring variation (2012), Imison, C. et al., London: The King’s Fund 11

Ibid.

a) Keeping people healthy and independent in the community

Delivering universal and preventative services

b) Local access to specialised health and social care model

Delivering targeted primary and community care services

c) Supporting people when they require hospital and residential services

Delivering acute care and care home services


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By 2016, we will provide services that deliver high quality, integrated care to our residents through implementation of out of hospital initiatives which:

support more patients to remain independent and receive care in their home or community

minimise preventable hospital admissions, increasing timely access to community-based out-of-hours and urgent care where appropriate

minimise residential placements, by supporting individuals to remain living in their own home

provide effective reablement and rehabilitation services to support people in the community

maximise self-care by supporting communities and individuals to look after their own health and wellbeing, especially for those with multiple LTCs

transform the way in which care is provided characterised by a wide variety of organisations (including those in the voluntary sector) working collaboratively

encourages independent community-based living which prevents social isolation and improves access to voluntary services which improve quality of life

provides an experience of joined up services, where professionals from different teams and organisations work together well, with appropriate and timely communication, supported by shared records


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Aims and Objectives

Aims

The aim of our Joint Strategy for Health and Social Care is to work in partnership to develop

high quality, integrated care, creating a service model where as many services as possible

can be offered in the community. The strategy will be driven by the Better Care Fund,

helping the LB Sutton and Sutton CCG work more closely together to reduce fragmentation

in patient pathways, and reshape care so that people are supported to remain well for longer

in their own homes and in community settings. This will require greater coordination between

primary and community teams, and greater engagement with the voluntary sector and other

service providers, with GPs at the hub of multidisciplinary teams working with shared health

and social care information and patient records.

We aim to meet the following reductions in demand by 2016/17:

To achieve this, we will:

In addition to setting the overall objectives for community-based services, our strategy also

addresses some of the challenges to delivering these objectives, and how we intend to

build capacity in the community to work collaboratively through integrated services to reduce non-elective admissions to acute settings and care homes;

build capacity in the community to respond to escalating or urgent care needs of identified people at risk, such as older people or those with multiple or deteriorating long term conditions;

expand the capacity of the reablement and rehabilitation services to support residents in the community, helping to reduce length of stay in acute settings and preventing readmissions by improved discharge planning;

realign the acute sector (Epsom and St Helier University Hospitals NHS Trust) to match changing demands and community capacity;

maximise people’s capacity to self-care – by supporting communities and individuals to look after their own health and wellbeing;

plan and develop a community workforce in collaboration with providers, which can deliver an expanded community service model, and transition professionals leaving acute settings into the community;

provide stronger links with voluntary services and other community groups, preventing social isolation and dependency where appropriate.

10% reduction in demand on A&E services, with 50% of this expected to be shifted to our UCC and 50% of demand to be redirected altogether

17.5% reduction on avoidable NEL medical admissions

5% reduction in outpatient appointments overall

25% reduction in hospital-based outpatient appointments


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overcome these. The strategy considers the enablers for delivering care in the way

described above. These include data sharing capabilities, organisational development and

processes to promote multidisciplinary working and care planning. It also includes

establishing closer links with primary care with the further development of community

services. Furthermore, we are committed to delivering a health and social care model which

expands capacity 7 days a week and provides the appropriate level of service out-of-hours.

We will therefore ensure that the appropriate resource and skill is available to assist the

transition into the integrated model of care provision.

Objectives

In order to deliver this strategy, we have developed a number of initiatives and defined

services which are aimed at improving the quality of care in Sutton and integrating health

and social care more closely so that more services can be provided in the community. We

have divided these initiatives into four broader categories:

1) Prevention

Nationally, the population is both growing and ageing; this is reflected in Sutton where there

are now some 18,000 people over the age of 6512. We also know that this older population

consumes a disproportionate amount of resources in primary care13, and that most will be

living with at least one long term condition14. There is consequently a sizeable population

that, without effective self-management, are at risk of their conditions exacerbating and

requiring hospital admission. It is therefore a primary objective of this strategy to provide

effective preventative and proactive care across Sutton.

Patient education is a significant part of prevention, as it encourages increasing self-

management, particularly for those suffering from multiple long-term and chronic conditions

such as Chronic Obstructive Pulmonary Disease, heart failure, diabetes and dementia.

Patient education should also include wider public health messages and interventions, such

as smoking cessation, obesity and alcohol reduction, as well as the benefits of health,

mental health including dementia and functional screening. The provision of information and

advice is the first level of support that people in the community will access, and clear

information will enable them to support themselves to live healthy lives and stay independent

in their community. Embedded within jointly commissioned schemes, we will focus on

ensuring that people are signposted to the correct services in a timely manner and provided

with support and education which meets their needs.

Our strategy on patient education does not only focus on informing patients about their

condition and how it can be managed; it is also directed at reducing service complexity for

patients by ensuring that services provided out of hospital are well-connected and easy to

navigate. We know that having many smaller, specific services may make the system more

complicated for patients15, and with the development of multiple new initiatives in Sutton, it

will become even more important to ensure that patients are informed about their options

12

Sutton Joint Strategic Needs Assessment (2012) Available from: http://www.suttonjsna.org.uk/index.html 13

A Call to Action -Transforming primary care in London (2014) Department of Health, London: Department of Health 14

Living in the 21st Century: Older people in England. The 2006 longitudinal study of ageing (wave 3)

(2008) Banks, J. et al. (eds), London: The Institute for Fiscal Studies 15

Community services: How they can transform care (2014) Edwards, N., London: King’s Fund


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and the availability of relevant services. Wider community resources promote wellbeing and

independence, and in Sutton are frequently provided by charities, voluntary and community

organisations, special interest and peer support networks and groups, and neighbourhoods.

We will ensure that our community and acute workforce, primary care teams and community

providers are committed to helping people to navigate and access services appropriately.

The implementation of risk stratification and active case management will also support

primary care as the hub and host for multidisciplinary team working, in providing proactive

care across Sutton. It will involve multi-professional teams including primary care,

community and social care professionals working to identify those most at risk of a hospital

admission. Teams will be accountable for implementing timely and practical measures to

help prevent admission, with a central coordinating professional who will be responsible for

ensuring people are actively involved in their care and plans are person-centred. This may

be either a health or social care intervention, or a combination of both. The role of the

informed and involved patient, together with a ‘system’ which encourages care coordination,

and professionals who have the capacity and capability to work together to provide such

care, has been well tested and referenced; as discussed in the ‘building the house of care’

for care coordination of those with long term conditions16.

For the frail elderly, falls are a significant cause of admission to hospital17 and are the

leading cause of ambulance call-outs to the homes of people over 6518; around 1 in 3 people

over 65 and 1 in 2 over 80 fall each year19. We also know that any hospital admission for the

frail elderly has the potential to lead to the loss of independence20. We will therefore provide

services that provide a range of support to those identified at risk of falling or losing

independence.

2) Supporting people to maintain their independence

As care shifts from acute settings to the community, Sutton CCG will support patients in

managing their own conditions by simplifying and integrating the services provided and

educating patients about their conditions. At a community level, the aim is to move to a

position where as many people as possible are enabled to stay healthy and actively

participate in society, and delaying or avoiding the need for reactive services such as

nursing care homes. The King’s Fund has observed that self-management can improve

health outcomes, improve patient experience, and reduce unplanned hospital admissions in

patients suffering from long-term conditions such as COPD21. We know that there are also

benefits associated when patients and clinicians are equally involved when developing a

personalised care plan22.

16

Delivering better services for people with long-term conditions: Building the house of care (2013) Coulter, A. et al., London: The King’s Fund 17

Making our health and care system fit for an ageing population (2014), Oliver, D. et al., London: The King’s Fund 18

Prevention package for older people resources (2009) Department of Health, London: Department of Health 19

Making our health and care system fit for an ageing population (2014), Oliver, D. et al., London: The King’s Fund 20

Older people and emergency bed use: Exploring variation, (2012) Imison et al., London: The King’s Fund 21

Transforming our Healthcare System (2013) Naylor et al., London: The King’s Fund 22

Ibid.


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Reablement, rehabilitation and care services are central to our Joint Strategy for Health and

Social Care in supporting patients to remain independent, or to reach their original level of

independence following a spell in hospital. More accessible and effective reablement is

associated with reduced delays in transfer of care, improved health outcomes23, reduction in

falls, greater independence and aims to delay or prevent admission into a care home. It is an

important service for older adults, who otherwise would suffer from a degree of frailty.

We will commission services that improve links with the voluntary sector in order to provide

holistic care and wellbeing, and address issues such as social isolation and loneliness. This

will offer people an opportunity to become an active part of their community, and ensures

‘lower level’ needs are met that allow people to remain in their homes for as long as is

appropriate for their welfare. It is recognised that technology is increasingly an enabler to

meeting this aim, through advances such as telehealth and telecare, and we will ensure that

these services are made available across Sutton to those who can benefit most.

Timely access to care is crucial for patients, particularly those with one or more long-term

conditions, and this must be available around the clock and seven days a week. Allowing

patients whose condition deteriorates to have access to effective support from practitioners

who already understand their condition thanks to the integrated care approach described

above. Case management, accessible records and capacity in community care services,

which have all been identified elsewhere in this strategy, are crucial; they allow effective care

to be delivered.

The benefits from integrated care are not just concentrated on preventing admissions and

patient experience; they also extend to patients with mental health issues. Our strategy

addresses our aim to deliver ‘parity of esteem’ when treating patients with mental health

difficulties, and initiatives such as Improving Access to Psychological Therapies (IAPT), for

example, will address the specific mental health issues associated with long-term conditions,

such as anxiety and depression.

3) Reducing non-elective admissions and lengths of stay in acute hospitals

In situations of crisis where a patient’s health rapidly deteriorates, the overall objective of the

Joint Strategy for Health and Social Care is to ensure that patients can receive access to

urgent care in settings away from hospital, where clinically safe and appropriate to do so.

The Keogh report highlights that up to 40% of A&E attendances are avoidable24. People at

high risk of an emergency hospital admission, such as those in care homes, should be

identified quickly and an alternative to A&E should be available at any time of day, and for

both health and social care needs. In addition, we need to have responsive hospital-based

services and professionals who are able to redirect people to more appropriate settings,

such as to urgent care services in the community.

Wherever possible and clinically appropriate, hospital admission will therefore become a ‘last

resort’ option. This strategy, however, does not stop at acute admission: we want to enable

patients to be discharged more quickly back to their own homes or to a community setting

where they can receive additional and appropriate care and support. This should prevent

23

Reablement: A cost effective route to better outcomes (reviewed edition) (2014) Francis, J. et al., London: Social Care Institute for Evidence 24

High quality care for all, now and for future generations: Transforming urgent and emergency care services in England (2013) Keogh, B., London: NHS England


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readmission to hospital, subsequent admission to a care home and increase independence

and functionality following hospital-based admission. Sutton CCG has been focusing on

initiatives which enable timely discharge from hospital, such as 7-day services in the

community and more effective reablement and therapy.

Planning for discharge and appropriate post-discharge support are key to reducing length of

stay and avoiding readmissions. Commissioners and senior decision-makers in hospitals25

will work with Social Services to ensure that this process is properly coordinated and that the

support services are in place. Health and social care support packages must be provided

promptly for all patients who are medically fit enough for discharge. Patients and their carers

should be fully involved with their own discharge plans, and should have access to early

supported discharge teams of community nurses, providing rehabilitation and personal care

delivered to a tailored plan. We know that this can be effective in reducing readmissions.

Post-discharge support not only includes access to physical therapy and care, but also

support for emotional and low-grade co-existing mental health conditions, or identified

memory problems. This will therefore include increasing access to specialist services such

as dementia services, as well as more holistic social and voluntary care support, such as

peer support and befriending services.

Intensive post-discharge support will reduce delayed transfers of care, create more capacity

in acute hospitals, prevent the unintended complications of long stays in hospital (such as

hospital acquired infections, and reducing mobility and independence) as well as improve

patient experience. We will ensure that both health and social care services shift to a 7-day-

a-week model to facilitate this.

This wider range of services also extends to end of life care. The objective around this will

be to ensure people who are nearing the end of their life receive timely and high quality care

with personal choice and control. Their preferences over place of death will be respected,

and inappropriate hospital admissions avoided. This will involve ensuring effective patient-

centred assessments and advance care planning, recorded through the shared record

platform, which includes their preferences and those of their carers and families where

relevant. It will also include improving end of life care for people with dementia, which should

include advance care planning for people with early stage dementia, training in end of life

competencies for informal and formal carers for patients with dementia, the involvement of

care co-ordinators in co-ordination end of life care and multidisciplinary guidelines specific to

people with dementia.

4) Improving quality of care

Shifting care to community settings is only worthwhile if the quality of care or patient

experience is improved at the same time. The Joint Strategy for Health and Social Care

focusses on providing unplanned and planned care where high quality can be effectively

delivered and achieved in the community. This has required clinical and commissioner

engagement across acute and community-based services in Sutton, and deliberation over

services which when shifted or expanded in the community can improve the quality, safety

and convenience of services in the community.

25

Senior decision-makers refers to senior clinicians, such as consultants, and ward level discharge planners


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Fundamental to delivering these quality improvements is the better integration of services,

which will require greater collaboration between providers and the teams. The development

of multidisciplinary teams that transcend traditional organisational boundaries is therefore a

priority. This will be enabled, in part, through the Better Care Fund, and will require an

advanced approach to commissioning that incentivises multi-professional health and social

care teams, whether through one provider, or providers working in collaboration.

Providing a wider range of options to patients in a community setting is a key element of the

Joint Strategy for Health and Social Care, as it enables patients and residents to receive

care closer to home, in a way which suits their needs. Our objective is to broaden access to

community and out of hospital care by working closely together and with community

services, voluntary providers, charitable organisations, and not-for-profit groups of medical

professionals when delivering services. Increasing access will improve patient choice,

convenience, experience and quality.

Through changing the way that services are accessed for the people of Sutton, we are

confident that services can become more responsive to people’s varying needs, where

access to specialist care can be improved, and outcomes can be improved.


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Priority Areas

In order to meet the strategic aims and objectives for out of hospital care in Sutton we have

developed a range of initiatives and schemes that together seek to deliver the vision set out

above. These initiatives have been grouped to reflect our five priority areas:

1) Long-Term Conditions

2) Planned Care

3) Older People

4) Providing Services Closer to Home

5) Urgent Care

Each of the priority areas will be described in summary below, with reference to the

initiatives included amongst them.

1) Long-Term Conditions

As the number of people living with one or more LTCs increases we will need to change our

approach towards providing care. Conditions such as COPD and diabetes require regular

management, both self-management by individuals as well as support from clinicians to

avoid exacerbation and in the worst case a non-elective hospital admission. For those living

with dementia, we not only need to ensure that appropriate services are available, but that

all health and social care professionals have relevant, up-to-date training, improving both

quality and outcomes.

Our approach is both proactive, to identify those with multiple LTCs and assist with

management and prevention, and reactive, where crises do occur the right services are in

place to respond and mitigate the effects. The proactive approach is covered in more detail

below; the reactive services are discussed further in the Urgent Care section.

We will use proactive initiatives such as risk stratification, which enables GPs to identify

those at greatest risk of unplanned hospital admission, and support this through active case

management. This will be supported by the implementation of multi-disciplinary teams

(MDTs), organised into localities and including clinicians from primary care, Sutton and

Merton Community Services and Social Services. There will be frequent meetings to discuss

those people at highest risk of hospital admission to ensure that the package of care that

they are receiving is appropriate and dealing with potential issues before they become

severe enough to warrant urgent care. Active case management will include case seeking.

We will look to move away from a traditional disease pathway focus towards a more

integrated service. We will ensure that specialist nurses are embedded as part of MDTs in

order to provide care and management to those with specific conditions, but also ensuring

that people’s wider health and social care needs are discussed and catered for.

We will also empower people with multiple LTCs to better understand their conditions and

safely manage them from home. Initiatives such as the COPD Health Coaching Pilot will

provide targeted training by registered nurses to reduce avoidable non-elective admissions

to hospital.


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Initiatives will also move the provision of care from a hospital setting to a community or

primary care setting. This includes services such as the Diabetes Tier 3 Pathway, that seeks

to provide care that would have traditionally have been a hospital outpatient to be provided

in a community setting. This will have an additional aim to ‘repatriate’ patients into lower tiers

of the service that are normally managed within primary care.

Long Term Conditions Initiatives

Diabetes Pathway (Tier 3 service)

COPD Pathway

Dementia Support

Case Management and Multidisciplinary Integrated Working

Mental Health Services

COPD Health Coaching Programme

Transition Pilot (Children moving to adult life)

Development of Learning Disability Service

A high level delivery plan for each of the initiatives is shown below; detailed descriptions and

timelines of each initiative can be found in the Appendix.


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Initiative Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

2013/14 2014/15 2015/16

Diabetes Pathway (Tier 3 Service)

COPD Pathway

Dementia Pathway

Case Management & Multidisciplinary Working

Service launched

Quarterly impact review







Recruitment of respiratory nurse








Teams organised into localities

‘New ways of working’

Integration of social care teams

Co-location of locality teams

Integrated locality team ‘business as usual’

WorkstreamAction Plans

Findings reviewed

Commissioning Intentions

Evaluation

Baseline and Objectives

New service(s) implementation


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2013/14 2014/15 2015/16

Mental Health Services

COPD Health Coaching Programme

Transition Pilot (Childrenmoving to adult life)

Development of Learning Disability Service

Develop / Implement performance management








Commissioning Intentions Developed

Service launched

Pilot mid-year review

Pilot full year review

Continuation decision

PCMHS Model Development

PCMHS Model Refined

Procurement (ITT and PQQ)

Implementation / Mobilisation

Provider Fair

New Service Launched

Pilot Scheme

Pilot review

Business Case


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2) Planned Care

Initiatives within planned care focus on ensuring that the right services are available to

people in a setting close to their homes. The first element of this is ensuring that the right

people are referred to the right place; to help prevent inappropriate referrals we will make

sure that GPs have access to advice from specialists. This will ensure that patients who

don’t need to make additional journeys to hospital are able to be managed in a primary care

setting.

Where a referral is unavoidable, we are committed to providing services in convenient

locations, close to where people live, that avoid the requirement for them to travel to

hospital. Both services that require a one-off visit, such as hernia repair, where a ‘walk in

walk out’ service will be provided, and those requiring frequent visits such as

anticoagulation, which will be delivered from primary care hubs will benefit from this

approach.

To support this aim, Sutton CCG has invested £13m in the Jubilee Health Centre, located in

Wallington, to where services that were previously located in an acute setting have been

relocated. We have drawn up a three and a half year plan in conjunction with Epsom and St

Helier and NHS Property Services to support the continued relocation of services into the

Jubilee Health Centre.

For patients with specific requirements, such as those on the heart failure pathway, planned

care initiatives are also designed to improve integration with primary care, embedding

specialist care into integrated MDTs, led by an accountable GP and centred around the

patient. Meanwhile rapid access to planned diagnostics supports services being provided in

a community setting.

Planned Care Initiatives

Anticoagulation Clinic

Gynaecology

Cardiology

Remote Advice from Specialist Clinicians

Heart Failure Pathway

Hernia Repair Service

Gastroscopy




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2013/14 2014/15 2015/16

Anticoagulation Clinic

Gynaecology

Cardiology

Remote Advice from Specialist Clinicians

Heart Failure Pathway(see Case Management & Multidisciplinary Integrated Care)

60% of patients transferred to primary care hub







Domiciliary care contract negotiation

Transition of remaining patients to primary care hubs

15/16 contract review

Maintenance of existing service









Maintenance of existing service








Procurement

Implementation / mobilisation

Service launch

Specification / delivery of GP education sessions



Transition to locality-based integrated MDTs


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2013/14 2014/15 2015/16

Hernia Repair Service

Gastroscopy


Implementation /


14/15 contract agreed

Service launch




Procurement


Service launch

Identification of

clinic location


Quarterly impact review Quarterly impact

review


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3) Older People

Care for older people in Sutton will be provided as part of an integrated Older Patients

Pathway, which has been developed as an expansion of the Integrated Complex Older

Patients Pathway that ran in 2013/14. The service will now cater to all people over the age of

65, and primarily aims to prevent attendance at A&E, non-elective admission from the Acute

Medical Unit (AMU) and, where an admission is clinically unavoidable, readmission to

hospital following discharge. The pathway includes a range of services which are, at the

core, supported by integrated, locality based, MDT working. Services offered as part of the

pathway include:

• In-reach/out-reach from community and social services improves continuity of care and discharge planning;

• Resource to follow up and monitor elderly respiratory discharges; • Daily integrated MDT approach to discharge planning, including primary care,

community care, social services and third sector supported by a patient ‘navigator’; • Discharge to hospital at home virtual ward services, facilitating shorter hospital stays

where appropriate; • Discharge to Community Rehab Beds and community rehab at home; • Home from Hospital Service; • ‘Next Steps’ discharge document, developed in collaboration with stakeholders • START – Reablement Service

The pathway will be closely aligned with urgent care services, such as Rapid Response (see

Urgent Care). Effective discharge planning is a core element of the service, with a range of

interventions at different intensity levels that can be called on to prevent crises following a

hospital stay from the low-level, such as a befriending service and the ‘next steps’ document,

though to the more intensive Hospital at Home service.

Supporting the Older Persons Pathway are services which act as ‘case finders’, such as the

Fracture Liaison Service. This initiative provides assessment of patients that present with a

wrist fracture are referred upon discharge to the FLS. The patient is then followed up by the

FLS nurse who further assesses the patient for further risk of falls and existing osteoporosis.

Taking a preventative approach, in collaboration with the community Falls Prevention

Service, has resulted in a reduction of the number of fractured neck of femurs being

recorded in Sutton26. The service is also identifying people suitable for inclusion in the

telehealth / telecare pilot (see Providing Services Closer to Home).

The Short Term Assessment and Reablement (START) service will also deliver an

opportunity to provide increased functionality and independence to older people. It is a

specialist homecare team which works with people on discharge from hospital or to prevent

admission to hospital and long term care. The team was expanded significantly in 2013,

providing an additional average 400 hours per week of care capacity and allows the team to

provide social work, occupational therapy and physiotherapy input.

For those approaching the end of life we will provide services that ensure people’s dignity

and wishes are respected, and that they are cared for in the most appropriate setting. A

CQUIN will support the expansion of the end of life community nursing which, in common

with other specialist nursing provided in the community, will form a part of integrated locality

26

Figures from SUS data: 2009/10- 206; 2010/11-190; 2011/12-178; 2012/13-170; demonstrating a reduction of around 15% per year.


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MDTs. In addition to providing care, these nurses will also up-skill workers in nursing and

residential homes, to proactively identify those approaching the end of life.

Sutton has a long record of using the Coordinate My Care (CMC) system, with completion

rates amongst the highest in London27. Community nurses will continue to ensure that all

those identified as approaching the end of life continue to have a record. In addition, we will

be working closely with Epsom and St Helier through a CQUIN scheme to develop a process

to link hospital records with CMC records, flagging those who are admitted that have

recorded a preferred place of care (PPC). Part of the scheme will also include training for

staff within both A&E and the AMU to support them in identifying those approaching the end

of life and in making appropriate clinical decisions.

Older People Initiatives

Fracture Liaison Service

End of Life: Coordinate my Care

End of Life: Community Nursing

Older People’s Pathway

START – Reablement Service

Personal Health Budgets



27

Figures obtained from Coordinate My Care, run by the Royal Marsden NHS Foundation Trust, 2013


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2013/14 2014/15 2015/16

Fracture Liaison Service

End of Life: Coordinate My Care

End of Life: Community Nursing

Older People’s Pathway

Osteogeriatrician to develop business case for expanded service








Recruitment of therapists








Business case review / approval


Expanded service launch

IT system spec. developed

Training spec. developed

Procurement

Training of A&E and AMU staff

Implementation and roll-out





Initiative launched








Up-skilling of nursing home / residential home staff

Recruitment of ‘navigator’

Recruitment of Consultant Geriatrician

Summer publicity campaign

Winter publicity campaign


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2013/14 2014/15 2015/16

START – Reablement Service

Personal Budgets

TBC








TBC

TBC

TBC

TBC








TBC

TBC

TBC


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4) Providing Services Closer to Home

Providing services closer to home and the expansion of community-based care is a central

part of our Joint Strategy for Health and Social Care. We have prioritised services and

schemes to deliver this, recognising that this provides greater convenience for the residents

of Sutton, higher quality of care that goes beyond providing treatment and support for

physical ill-health and creates a person-centred offering. Fundamentally, it will also mean a

reduction in demand and pressure on acute services, so that only those patients who require

specialist care and expertise where it is appropriate to deliver at a hospital site, will be seen

in hospital.

Our strategy to expand and implement services closer to home includes providing expanding

community estate where people can receive care, diagnostics and some selected specialist

care co-located on one site. This includes the development and opening of the Jubilee

Health Centre based in Wallington. In addition, improving the experience and

responsiveness of care delivered in the community is a key priority. Therefore we have

concentrated our efforts on increasing the availability and uptake of technology-enabled

solutions for vulnerable groups, such as older people at risk of falls at home. We have

planned a pilot telehealth/telecare scheme which provides a home monitor for selected

cohorts of patients who have been identified at high risk of falls through previous fracture or

through the falls prevention service. Interventions will then be delivered to patients triggering

a risk of falls according to the results of monitoring.

Improving care and responsiveness for people who are discharged from hospital will also

progress the quality of care in the community, paying attention to their needs holistically.

This will include improving their functionality, preventing social exclusion, supporting access

and signposting to alternative services, and supporting them with their concerns, which can

all if unaddressed lead to negative consequences; namely readmission into hospital,

permanent admission into residential or nursing care, reduced mobility leading to new

medical complications such as falls or pneumonia, and mental health problems including

low-grade anxiety and depression. This includes the Home from Hospital service which will

identify vulnerable older persons being discharged from hospital and provide low intensity

support at home preventing re-escalation of their condition.

We intend to commission community services which provide holistic and person-centred

approach to people needs, addressing gaps in their social, health and their mental wellbeing.

In particular the Community Choices pilot which provide highly accessible and responsive

access to short-term and mental health care and practical support with day-to-day activities

through an allocated key worker. Similar support will also be offered to appropriate people at

risk of escalating mental health issues, through the peer support pilot. The pilot is developing

a peer support network with the aim of increasing the number of trained Peer Supporters to

support individuals to maintain their health recovery and independence.

A key part of this category of initiatives is availability. Sutton CCG and the LB Sutton are

working on integrated initiatives which provide different services, such as telehealth/telecare

and peer support. The aim of these is to reduce non-elective admissions and A&E

attendances as well as increase independence. Patients will be able to access beds, one-

on-one support and other health services in their community. Many of these initiatives link

with other initiatives in different categories (such as Older People, Urgent Care) as providing

services closer to home is not specific to certain conditions or patients.


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Another significant part of improving support and therapy in the community, and preventing

escalation of medical conditions and functional decline, is providing intensive and timely

access to intermediate care and rehabilitation. Our community rehabilitation service is able

to provide home-based and bed-based coordinated therapy, nursing and social care to older

people identified as requiring intensive support, as well as signposting to other community

services such as Speech and Language Therapy (SALT), falls prevention service and

community nursing where appropriate.

Supporting carers is also a key joint commissioning responsibility to be delivered through

improving our Joint Strategy for Health and Social Care. This includes support, respite and

education to informal carers and family members, which we will deliver through our BCF plan

and will link in with the anticipated duties from the Care Bill.

Providing Services Closer to Home Initiatives

Jubilee Health Centre

Community Inreach and Outreach

Telehealth / Telecare

Home from Hospital

Community Rehabilitation Beds

Community Choices Pilot

Peer Support

Supporting Carers

Food Poverty Pilot

Evaluation of Integration Pilots

Data Sharing

Developing Provider Market through Personal Care Framework




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2013/14 2014/15 2015/16

Jubilee Health Centre

Community Inreach and Outreach

( See Older Patient’s Pathway )

Telehealth / Telecare

Home from Hospital ( See Older Patient’s Pathway )

Community Rehabilitation Beds

Phase II services identifiedT








Phase 2 services

implemented Review phase 1 services

as part of contracting

round

Service launch

Service modelling

Specification developed

Procurement











Identification of suitable pilot patients

Pilot launch Implementation

/ mobilisation

Mid - point review Review

Full - year review Review

Contract decisions

Provider appointed


TBC TBC


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2013/14 2014/15 2015/16

Community Choices Pilot

Peer Support

Supporting Carers

Food Poverty Pilot

Evaluation of Integration Pilots

Data Sharing

Developing Provider Market through Personal Framework


3 month service review

6 month service review

Future commissioning discussions

End of pilot


Service review

Development activity

TO FOLLOW

TO FOLLOW

Review pilot outcomes and bus. cases

Pilot Scheme

Pilot review

Business Case


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5) Urgent Care

Provision of urgent care is traditionally associated with acute services and secondary care

settings. However, our Joint Strategy for Health and Social Care incorporates providing

urgent care at a community level in order to redirect people with escalating needs away from

acute services where secondary care services are not required. Ideally these services will

also prevent escalating needs shifting to medical or mental health complications or crises.

Therefore community-based urgent care services form part of our reactive approach to

delivering out of hospital services

We have jointly developed initiatives which provide responsive urgent care services in the

community, such as our Community Prevention of Admission Team (CPAT) and START

(see Providing Services Closer to Home). These services are designed to provide urgent

care at short notice to a patient’s home following identification and referral by their GP. The

aim is to prevent emergency admissions including from residents in care homes, which have

a high proportion of patients who require acute services. Once the initial management has

been completed by emergency care nurses, further care planning and treatment can be

delivered within the community maintaining stability and referring for planned care and

therapy as required.

Other initiatives which also address prevention of admission include the Out of Hours and

111 services, which aim to prevent admission to secondary care by providing access to care

and signposting outside of core hours. The recently developed Urgent Care Centre at St

Helier’s Hospital, aims to redirect around 50% of attendances including children, presenting

in the emergency department to receive care from GPs and other primary care

professionals. The Urgent Care Centre is co-located with the emergency department and our

local out-of-hours service hub, provided in a specially equipped and designated department.

Co-located in the emergency department is the Rapid response multidisciplinary team who

are responsible for identifying those people where coordination of and responsive

community care can avoid admission to hospital. To compliment this, our urgent care

strategy will also implement the Ambulatory Care Service (ACS) which aims to provide

appropriate care in the emergency department with further follow-up arranged either in

hospital or ideally in the community, where specific care pathways where an overnight stay

in hospital is not required. Further engagement with our acute trusts is taking place as well

as south west London-wide programme to facilitate development of ACS care.

The community-based urgent care also includes early intervention and prevention of

conditions that will if unchecked or not prevented will require hospital-based treatment.

Schemes which we are delivering to address this includes our risk assessment Pressure

Ulcers scheme (national CQUIN) and our falls prevention service where therapy to improve

mobility and avoid hazards is delivered at home and in the community, and through

assessment in clinic.

Urgent Care Initiatives

Rapid Response

Urgent Care Centre

Ambulatory Care Services

Out of Hours Service


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111 Service

CQUIN: Pressure Ulcers in the Community (National CQUIN)

Community Prevention of Admission Team

Community Falls Prevention Service

Raising Awareness of Local Urgent Care Services

GP First Patient Access Scheme




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2013/14 2014/15 2015/16

Rapid Response

Urgent Care Centre

Ambulatory Care Services

Out of Hours Service

111 Service

CQUIN: Pressure Ulcers in the Community

( National CQUIN )

Quarterly performance monitoring










Agree entry / exit points

Identification of single unit for ACS

Recruitment into new posts

Paed . Consultant lead named

Develop streaming model

Agree diagnosis list

Phase 4 Launched

Implementation/ mobilisation

Monthly reviews via UCC Clinical Oversight Group

Single ACS Unit

Service review

Operational with quarterly review

Operational with monthly contract

meetings and clinical governance


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2013/14 2014/15 2015/16

Community Prevention of Admission Team

Community Falls Prevention Service

Raising Awareness of Local Urgent Care Services

GP First Patient Access Scheme








Evaluation of CQUIN

Implementation

Review

Integration of systems to accept LAS referrals








Pilot practices identified

Pilot Launched

Pilot Review

Roll-out decisions

Governance

We recognise that our governance structure and our inter-organisational relationships will be core to the implementation and success of our

Joint Strategy for Health and Social Care in Sutton. In order to plan for co-commissioning and our Better Care Fund plan we have developed

governance and commissioning structure which has enabled us to make decisions in order to develop our approach.

Current Arrangements

Health and Wellbeing Board

This board is responsible for overall governance and alignment of objectives, and is chaired by the Council Leader. It contains representatives

from the Council who have responsibility for health and social care, representatives from Sutton CCG including the Chairman of the Board, and

representatives from local voluntary sector providers. Its remit includes;

Ensuring that the Sutton JSNA is developed and delivered across the borough

Developing a Joint Health and Wellbeing strategy is developed and delivered across the borough

Statutory duties and responsibility over the planning and implementation of the Better Care Fund schemes

One Sutton Commissioning Collaborative

The purpose of the One Sutton Commissioning Collaborative (OSCC) is to support the Health and Wellbeing Board to commission in new ways

to meet the health and social care needs of the people of Sutton, ensuring that the commissioning of all its services achieves best value for

money. Its membership is drawn from commissioners only, and is divided between Health and Council membership. It meets monthly and the

Chair role alternates between the Council and CCG.

The One Sutton Commissioning Collaborative will provide a forum for commissioning, development and implementation of services for adults

and children living within the London Borough of Sutton or registered with a GP practice in the borough. It works across the commissioning

cycle and is the lead for delivering integrated and effective care services.

Future Governance Structure

Reorganisation of our governance will be required in order to deliver our aims and objectives. The following governance structure is planned to

be approved and operational in June.

the governance structure and relationships between Sutton CCG and LB Sutton

The intention is that the remit of the Health and Wellbeing Board remains the same; the OSCC will be a meeting that will be held in two parts.

One will be commissioner only the other part will enable the attendance of providers, strategic partners including the voluntary sector. The

purpose of this part of the meeting will allow strategic discussion to take place, escalation and resolution of any issue at a very senior level.

The Transformation Programme is created to deliver the Joint Strategy for Health and Social Care and commissioning decisions of the HWB

and OSCC. This is intended to be the operational delivery of the transformation programme which is focussed on the delivery of the better care

fund initiatives and other transformational system changes. Currently five separate work streams, aligned to the five categories of initiatives,

would report in to the Transformation Committee on progress.

Transformation Programme Board

One Sutton Commissioning Collaborative

Health and Wellbeing Board

Prov. Services Workstream

Urgent Care Workstream

Older People Workstream

Planned Care Workstream

Long Term Conditions

Workstream

Risks and Issues to Delivery

We have set ambitious plans and targets which will require careful implementation and evaluation as we move forward. Identifying risks to

delivering our joint strategy will help us to face upcoming potential challenges and allow us to manage them and put in place mitigating actions

to avoid risks to implementation of schemes where possible. The risks reflect the strategic risks of both the LB Sutton and the CCG and in

particular focus on the risks associated with integrated working and reconfiguration of services both locally and across the strategic planning

area of SW London. A register of identified risks is shown below:

No Risk Rating Mitigation

JHSC1 Risk of failing to align Call to Action, Better Care Fund programmes and the Health & Social Care Strategy, as a result of conflicting perspectives, which may result in failure to develop locally owned and credible Strategic Plan

High Joint work between Sutton CCG and LB Sutton to develop joint plans, which create a clear link between the Call to Action, Better Care Fund, Joint Health and Wellbeing Strategy and Care Act

JHSC2 The BCF fails to deliver forecast shifts to activity in 2015/16, driving financial pressures in commissioners and providers.

High Detailed planning with NHS and social care providers to follow BCF submission to ensure providers meet performance and cost targets. A specific training and development programme in 2014/15 to ensure delivery of the cultural shift. Additional QIPP targets and a Sutton CCG reserve to cater for this contingency.

JHSC3 Provider failure to deliver better ways to meet needs in the community that trigger risk of demand upon the acute hospitals or care homes being high and targets in reducing admissions to hospital or care homes and reducing DTOC

Medium Ensure preparation in 2014/15 on the integration of delivery against performance targets, including joint assessments and services in community. Evaluation of pilots and key integrated services, such as reablement. Close joint working with the acute trust on reducing delayed transfers of care and risk escalation in commissioning

JHSC4 Introduction of Care Bill results in a significant increase in the cost of provision of care from 2016 onwards and impacts on current planning, potentially resulting in failure to protect social services as required by the Better Care Fund

Medium Detailed planning after the BCF submission to ensure long term resource planning matches efficiencies from integration, and especially from the implementation of the Care Act. Some central government funding proposed for this but unclear as to whether all of it is within the BCF, and DH has promised that under New Burdens deal that all new duties will be fully funded.

JHSC5 Tension arises between partners on the definition of 'protection for social services with a health impact'

Medium Local definition of protection of social services. Regular meetings of senior teams in CCG and council, led and attended by CCG Chief Officer and Strategic Director Adult Social Services, Housing & Health. All schemes in plan fully debated and understood. Transparency over financial plans on both sides including savings. Shared performance metrics so impact of schemes and performance of whole system can be monitored

JHSC6 Shifting of resources towards community providers destabilises one (or more) acute providers due to the cumulative impact of multiple BCF plans across the area

Medium Impact will be monitored through SWL Collaborative Commissioning and overall 5 year strategic plan

JHSC7 Complexity of measuring success of individual initiatives leading to an impact on the pay by performance element of the BCF

Medium Each scheme is being measured to an aggregate level to ensure appropriate savings can be attributed to each scheme

JHSC8 Failure to deliver data sharing project between health and social care undermines integrated service delivery

Medium Separate work stream solely focussed on this work stream with commitment form all partner organisations for this to happen

JHSC9 Existing programmes, such as QIPP and social care efficiency programmes, lead to 'double-counting' of savings

Medium All schemes have been reviewed to ensure that the data sets used triangulate with each scheme to ensure that there is no double counting. The finance and performance group will also monitor these schemes on a monthly basis. Additional scrutiny will take place by an external agency on QIPP/BCF assurance

JHSC10 Scheme(s) deliver less than 70% of performance resulting in recovery plans being implemented and control over schemes is ceded to NHS England

Medium A realistic savings target has been applied to the BCF and as such this means that there is system confidence that the scheme can be delivered

JHSC11 Increasing demand on services (through demographic factors such as an ageing population as well as increased service expectation) means that targets cannot be met and benefit of increased community capacity is not realised

Medium Integrated and increased joint commissioning capacity. Close monitoring of demand in community with GPs, community health with social services and the acute hospital to align resources to match demand.

JHSC12 Sutton and Merton Community Services contract has only been renewed for one year therefore impetus for long-term changes in way of working may be lacking

Medium The provider is expected to meet the terms of its contract and this is measured robustly on a monthly basis. The provider is expected to want to work closely with the plans to ensure it is in a commercially strong position in preparation for retendering.

JHSC13 Health and social care working practice may not change as rapidly as required by QIPP/BCF plans

Medium There is a separate workforce and culture work stream as part of this project and will address this issue - including training and development

JHSC14 The BCF is a new policy change requiring new ways of working between stakeholders (i.e. LAs, CCGs and HWBs) which could require support to develop, and culture may not change sufficiently or fast enough to deliver plans

Medium Sutton has developed a governance structure that brings together leaders from both the CCG and LB Sutton as the One Sutton Commissioning Collaborative - this considers issues of integration including organisational development and training requirements, this group will consider future OD requirements required to transition to new ways of working

Documents

The Joint Strategy for Health and Social Care in Sutton · 1 Number taken from ‘Key Health Facts for Sutton 2012/13’, The Joint Strategy for Health and Social Care in Sutton (2014)