Event cluster presentation mar 15 v6 17 3-15

Integration of

health and social care

in Wokingham borough

Haveyour say

Today’s Agenda

• Hear more and

contribute to our plans

on integrating care

across Wokingham

Borough

• Look at one particular

scheme in more detail;

grouping services

around neighbourhoods

Today’s session will include

• A presentation from

Wokingham Borough

and the CCG

• A chance to see the latest

film describing our plans

• Group discussion

considering important

questions around how we

take the plans forward

Integration of health

and social care- Stuart Rowbotham and Katie Summers

Why integrate?

• What you have told us

at Call to Action events

• Care for people as

individuals

• Changing population

• Financial sustainability

People with more than one

long term condition, often

with complex needs, may be

visited or contacted by a

number of different people

from different departments in

different organisations who

may not fully understand the

individual’s overall needs.

Five Year Forward View

• New models of care and joint commissioning

• A stronger role for the voluntary sector

• Valuing the role of District General Hospitals

• Transformed primary care

• Greater emphasis on improving public health

• People more in control of their own care

• Better use of innovative technology

Implementation of Care Act

• Implementation of new eligibility criteria and

assessments

• New entitlement to services for self-funders and

carers

• Information and advice

• Prevention

• Statutory Safeguarding Board

The Better Care Fund

• Designed to deliver more services provided in

the community, developed in partnership

between health and social care

• From April 2015

• Pooled budget £9.5m

• 9 Schemes, including neighbourhood clusters to

enable local services to work more closely

together

• Care provided by multidisciplinary, multi-agency community teams.

• ‘Generic workers’ providing routine straightforward nursing, rehabilitation and personal care.

• Care managers who will act as an interface between an individual and their care team and coordinate the care for that individual.

• Sharing of staff, facilities and information.

• Identification of people who are not yet in crisis but at risk of getting to crisis point.

• Single points of contact will have replaced multiple information sources about what health and social care services are available locally.

• People will be supported in managing their own long term conditions.

• There will be growth in personalisation to ensure that care packages meet individual people’s needs and choices.

• Funding increasingly being managed through personalised budgets

What could success look like?

A new chapter:

Sam’s story in Wokingham

Supporting Sam

through

Neighbourhood

Cluster Teams

Why Neighbourhood

Cluster Teams?

Local people have called for

“More joined up services ”

“Telling our story once”

“Better access to local

services”

Local professionals are asking for:

Local named contacts

Service coordination

Shared decision-making

A changing population

Financial challengesNeed to value and develop local people and organisations

What might a Neighbourhood

Cluster look like?

• Population of 50 - 60,000

• A central point (e.g. library, GP practice)

for some services

• Certain services use cluster

as catchment areas for caseload

• Named contact(s), shared

between teams within clusters

• Shared care plans

Benefits of

Neighbourhood Working

for residents for the health and social care system

Promotes preventative, social

approach

Earlier interventions, reducing risk

of non-elective hospital admission

Continuity of care

Flexible deployment of resources,

breaking down unnecessary

organisational barriers

Contributes to ambition that

residents tell their story only onceReduction in duplication of tasks

Services are more local

Improved integration, including

with the community and voluntary

sector

People are treated as individuals Shared care plans, reviews etc.

Neighbourhood Geography

• Loddon Vale

• Parkside

• Woodley

• Wilderness

• Twyford

• Wargrave

61k rising to 64k

• Brookside

• Swallowfield

• Shinfield

41k rising to 59k

• Woosehill

• Wokingham MC

• Burma Hills

• Finchampstead

• New Wokingham

Road

59k rising to 70k

Practices and changes in population from now to 2022

(taking into account new housing developments)

Developing

Neighbourhood Clusters

EAST WEST NORTH

Development of Cluster Integration

SMARTER working

Focus on priorities e.g. GP-social care interface

TRIAL OPTIONS IN EACH CLUSTER

Community &

Voluntary Sector

coordination

Urgent

Care

Generic

Primary Care Nurse

e.g. wrap-round

services for

identified clients

e.g. hub/spoke model

for delivering

extended access

combination of practice

and community

nursing roles

Path for

Cluster development

2015 2016

Jan Apr Jul Oct Jan Apr Jul Oct

Development

of options

Trial option

in each cluster Possible

roll out

across

clusters Development

of business caseEVALUATION

CONSULTATION AND ENGAGEMENT

Time for discussion

1. Cluster Working

2. Community and Voluntary Sector Coordination

3. Extended GP Access

4. Self Care / Primary Prevention

5. Anything else...?

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23rd – 27th March