1. Epsom Health and Care
Working in Partnership and Developing the Focus on Prevention and Pro-active Interventions

2. What is Epsom Health and Care?
A local population of 200,000
Population-health based approach defined by 20 GP practices of Epsom Locality (GP Health Partners Ltd)
All main providers involved working together as a formal alliance or joint venture
Providing services together as ‘one team’ sharing the same identity and outcomes
EHC is a joint venture between 4 partner organisations : Epsom and St Helier’s Trust, Surrey County Council, Central Surrey Health and the local GP federation – (GPHP).
A 2 year business case was agreed in April 2016 and we have since then been developing a new full population health model, new ways of working and new relationships between providers, VS, D&Bs, patients and communities

3. Our commitment to forming an equal partnership with local people
Over 200 local residents and carers were consulted in the development of service with over 30 engagement sessions
Lay representatives contributed to service design and implementation assurance
The Lay Partners Advisory Group is the formal representation at meetings.
LPAG representatives are equal partners at every level of our governance including the Alliance Board
And are leading some of our key workstreams – including carers

4. In 2016 we started EHC @home service – our first fully integrated service
Intensive, multi-disciplinary care packages help people stay at home
Physicians, community matrons, nurses and others work together in a single team
Emis web enables recording and communication of people’s status
service (including Community Assessment and Diagnostics Unit)
MDT enhanced support – able to respond within 2 hours to keep people at home or bring them home when medically optimised
Enhanced care 72 hours with reablement up to 6 weeks
CADU – immediate access to diagnostics and specialist advice
Community Hub
Community based coordinated health and social care for people with complex conditions
Short term intense care and care planning
Multi-disciplinary care & care coordination
Allows people to stay at home, regain independence and prevent admission
Take slide from other presentations/ team working together

5. Our Business Plan for the next two years builds upon what we have achieved in 2016 /17 Business plan for 2017/19
The EHC business plan will therefore aim to achieve five main aims:
Develop the care model for people aged 65 and over
Lay the foundations for full population health
Prepare for integration to EHC through service transformation and redesign
Oversee the changes to the operating model to establish neighbourhoods across Epsom
Agree the arrangements required to establish an ACS system

6. The new care model cannot be implemented without changing the way care is organised
As part of the requirements for a full population health model of care, care will be delivered in neighbourhoods. Neighbourhoods will consist of networks of GP practices and will provide locally-based care for communities of 30,000 to 50,000 residents. Led by GPHP, we will work together, with local communities and wider partners throughout /18 to establish the benefits and the best configuration with a commitment to configuring care around local neighbourhoods over 2017/19

7. Shifting the Focus towards Prevention and Pro-active Interventions
While our initial focus was around changing the way care is provide
for older people who are already seriously unwell – to bring about
sustainable change we also need to focus on keeping older people
healthier for longer- this means an increased emphasis on prevention
and pro-active interventions targeting people who are currently
(relatively) healthy – this includes:
Identifying healthy individuals who may be ‘at risk’
Care planning focused on self-management and personal goals
Signposting and referring individuals to voluntary sector and D&B services, low intensity support services and services such as ‘in-touch’
It is anticipated that we will evolve into fully fledged ‘local hubs’
orientated around GP practices with existing and expanded services
through better integration and closer working with wider partner
organisations

8. Working with Partners – examples include:
Creation of new post – Surrey-wide Communities Prevention Lead
Working both pan-surrey and locally to identify opportunities for co-
working, coproduction and development of local initiative's
Surrey Downs Participation Action Network – working in an equal relationship and building sense of shared ownership with patients, voluntary sector and community to improve services and outcomes, spot areas of development, ensure equal access and ensure services meet the needs of our local population
Development of various workstreams (as part of EHC) which includes:
embedding lay partnerships, falls and Carers
Understanding Local Need - Using ‘tableau’ software to understand and compare local areas of demand with availability of services
Development of Mid Surrey Preventative Group (including commissioners, D&Bs, VS, VAMS Mental Health etc.) with locality workstreams and Mid Surrey Prevention Plan

9. Examples of Local Partnership Initiatives
Social/Well-being Prescribing – 3 models being tested across Mid Surrey. E&E model – community asset approach, project group established, working with local GPs, utilising local services
Partnership bids re Sports England funding – to develop initiatives to support older people to become more active and regain confidence (e.g. community coaches, indoor bowls for beginners, swimming with support etc)
Co-location opportunities
Embedding Lay Partnerships – understand role of citizens in new development new models, explore ways of enhancing ongoing engagement and coproduction, development wider lay Members forum, development of carers action plan and carers prescription

10. What do we want people to be able to say about EHC by the end of 2017/19?

11. For further information….