Excellent healthcare – locally delivered

Voluntary and community sector

engagement on Commissioning

IntentionsJuly 2015

Healthier South East London

The South East London Strategy

2015-2020

South East London (SEL) Vision for the future of health and care services

In south east London we spend £2.3billion in the NHS. Over the next five years we aim to achieve much better outcomes than we do now by:

• Supporting people to be more in control of their health and have a greater say in their own care• Helping people to live independently and know what to do when things go wrong• Helping communities to support one another• Making sure primary care services are consistently excellent and have an increased focus on

prevention• Reducing variation in healthcare outcomes and addressing inequalities by raising the standards

in our health services to match the best• Developing joined up care so that people receive the support they need when they need it• Delivering services that meet the same high quality standards whenever and wherever care is

provided• Spending our money wisely, to deliver better outcomes and avoid waste.

The local Commissioning Intentions plan for Bexley will need to reflect and be underpinned by the SEL plan. Clinical Leads, commissioners and the GB members are all actively involved in determining

the SEL plan and agreeing the improvements.

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How is the SEL vision to be achieved? By improving and transforming 6 priority areas of care:(referred to as Clinical Leadership Groups (CLG’s))

1. Community Based Care and Local Care Networks2. Planned care3. Urgent and emergency care4. Maternity5. Children and young people6. Cancer

The overall Whole System model and a schematic for each CLG, together with the key initiatives are shown in the following slides.

In addition to the CLGs there are also other enabler work programs & initiatives for:• Prevention: Smoking, alcohol and obesity• Work force• Developing Strong & Confident Communities

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SEL whole system model 5

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The strategic commissioning framework• A new vision for general practice• A new patient offer described in three

service specifications:

• A description of considerations for making it happen

Serving geographically coherent populations

between 50,000 – 150,000

The Community Based Care / Local Care Networks Target Model

• Leadership team• All general practices working at

scale (federated with single IT system and leadership)

• All community pharmacy• Voluntary and community

sector• Community nursing for adults

and children• Social care• Community Mental Health

Teams• Community therapy• Community based diagnostics• Patient and carer engagement

groups

‘The Core’ (as a minimum all LCNs should encompass)

• Strong and confident communities• Accessible HOT clinics and acute

oncology (urgent and emergency and cancer care)

• Specialist opinion (not face to face) and clear specialist service pathways

• Pathways to MDTs • Integrated 111, LAS and OOH

system (interface with UCCs co-located with ED model)

• Housing, education and other council services

• Community based midwifery teams • Private and voluntary sector e.g.

care homes and domiciliary care• Cancer services • Children’s integrated community

team and short stay units• Rapid response services• Carers• And there will be others..

Working with…

• Supporting patients to manage their own health (Asset Mapping, Social Prescribing, education, community champions etc

• Prevention – Obesity, Alcohol and Smoking

• Improved Core general practice access plus 8-8, 365

• Enhanced call and recall – improves screening and early identification and management of LTCs

• Reduction in gap between recorded and expected prevalence in LTC

• Supporting vulnerable people in the community including those in care homes and domiciliary care

• Reduction in variation (level up) primary care management of LTCs

• Reablement – Admissions avoidance and effective discharge

• MDT configuration – main LTC groups (incl. MH) and Frail elderly

• End of Life Care

Big hitters

Bexley

Bromley

Greenwich

Lewisham

Lambeth

Southwark

Integrated Pathways of care

Integrated Single System Leadership and Management

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Community-based care delivered by Local Care Networks

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Our context and focus in Bexley • Growing population, particularly in the

north• Primary care needs to be sustainable in

the long term• Need consistently excellent services

across the borough that patients are happy with

• Increased focus on prevention - e.g. childhood obesity

• Reducing variation in healthcare outcomes –addressing inequalities

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Proactive care • Roll out a social prescribing project across Bexley that reflects different localities health and wellbeing priorities

• A targeted self-management support initiative to be scoped and delivered in each locality• Community Health and Wellbeing Champions trained and working in each Local Care

Network• Active support of screening programmes by contacting patients who have not attended

bowel, breast or cervical screening invites• Targeting health promotion/ awareness raising activities• Reducing the proportion of the population that are unregistered• Childhood obesity prevention programme• Joint prevention programmes with schools to improve health/attendance of school age

children

Accessible care • All practices open during routine hours where building unlocked, practice receptionists answering phones and appointments running

• Explore new ways of working such as telephone triage, web consultations so that all patients in Bexley have same day access to a GP/nurse

• Up-skilling the workforce so that HCAs, Nurses, Pharmacists can take on more workload allowing GPs to deal with most complex patients

• Every practice to give patients option to book appointments four weeks in advance• A locality/borough-wide model developed for delivering extended hours • Every practice has a hearing loop in use by March 2016• Every practice has access to sign language interpretation

Coordinated care • Local Care Networks developed in line with south-east London strategy• Integrated care plans and case management in place for those at risk of exacerbation• Patients newly diagnosed with a long-term condition receive self-management/self-care

support • A comprehensive system and process in place for practices to utilise community geriatrician

resource for the most complex frail elderly

Your thoughts on primary careIs there anything else we should be doing?

What can you contribute? How can you work with health partners to progress these actions?

Proactive care

Accessible care

Co-ordinated care

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