the joint strategy for health and social care in sutton · 1 number taken from ‘key health facts...
TRANSCRIPT
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
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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
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Recruitment of respiratory nurse
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
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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Initiative Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
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
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
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
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
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
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Domiciliary care contract negotiation
Transition of remaining patients to primary care hubs
15/16 contract review
Maintenance of existing service
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
15/16 contract review
Maintenance of existing service
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Procurement
Implementation / mobilisation
Service launch
Specification / delivery of GP education sessions
15/16 contract review
Quarterly impact review
Transition to locality-based integrated MDTs
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Initiative Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2013/14 2014/15 2015/16
Hernia Repair Service
Gastroscopy
Quarterly impact review
Implementation /
15/16 contract review
14/15 contract agreed
Service launch
Quarterly impact review
Quarterly impact review
Quarterly impact review
Procurement
Implementation / mobilisation
Service launch
Identification of
clinic location
Quarterly impact review
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
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.
27
Figures obtained from Coordinate My Care, run by the Royal Marsden NHS Foundation Trust, 2013
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Initiative Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
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
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Recruitment of therapists
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Business case review / approval
Implementation / mobilisation
Expanded service launch
IT system spec. developed
Training spec. developed
Procurement
Training of A&E and AMU staff
Implementation and roll-out
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Initiative launched
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
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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Initiative Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2013/14 2014/15 2015/16
START – Reablement Service
Personal Budgets
TBC
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
TBC
TBC
TBC
TBC
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
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
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
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
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Phase 2 services
implemented Review phase 1 services
as part of contracting
round
Service launch
Service modelling
Specification developed
Procurement
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Identification of suitable pilot patients
Pilot launch Implementation
/ mobilisation
Mid - point review Review
Full - year review Review
Contract decisions
Provider appointed
Implementation / mobilisation
TBC TBC
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Initiative Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
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
Implementation / mobilisation
3 month service review
6 month service review
Future commissioning discussions
End of pilot
Implementation / mobilisation
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
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
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
Quarterly performance monitoring
Quarterly performance monitoring
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
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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Initiative Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
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
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Evaluation of CQUIN
Implementation
Review
Integration of systems to accept LAS referrals
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
Quarterly impact review
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