1. Delivering Better Care in South Gloucestershire

2.  National policy – a tool to drive joined up working between health and social care  £3.8bn p.a. from 2015/16 into a pooled fund to promote joint commissioning of services  Focus on achieving an agreed reduction in emergency admissions to hospital What is the Better Care Programme? What is the BCF?

3. Challenges  Not ‘new money’  Challenges of integrating commissioning and service provision  Fund is also expected to fund new obligations arising from the Care Act Opportunities  Help individuals manage their care more effectively  Move care closer to home  Reduce length of stay in hospital  More effective use of staffing and resources  Opportunities for joint working across health and social care  Communicate/engage with community Challenges & Opportunities What is the BCF?

5. What is the BCF really about? Everyone has a story…. What is the BCF?

7. The Local Challenge Each of our stories can be multiplied across our population  Unprecedented population growth  2018: 283,700 (4% growth)  2035: 313,600 (15% growth)  Aging population  Residents aged 85+: 27% growth (by 2018)  Pressure on finances – household and public sector Why your stories matter?

8. The Local Challenge A&E attendances: 5.5% (by 2018) Hospital admissions: 8% (by 2018) Residential care admissions: 33% growth (by 2020) Each story impacts

9. The Local Challenge These outcomes are not good for the people of South Gloucestershire and they are not sustainable for our organisations. So……. “What would it take to develop a network of support around individuals that empowers them to remain independent and well for as long as possible?” The Local Challenge

10. What are we doing? There are many things that are already in development:  Focus on caring and supporting people with dementia  Connecting Care – a method of sharing information between organisations  Enhancing capability of local care homes  Developing a Rehabilitation, Reablement & Recovery approach (to avoid unnecessary admissions and reduce long stays in acute hospital beds) But what else could we achieve if we work together? We have started

11. What are we doing?  We are testing the idea of developing services based around six parts (clusters) of South Gloucestershire.  The Cluster Model has been developed around groups of GP practices.  The aim is to improve the way services are provided for local people  To do this we need to understand the full range of organisations and services that support people within the cluster (statutory and voluntary) and the role they can play. The Cluster Model

12. Cluster Map

13. Cluster Populations What are we doing? Locality – SevernVale/Yate Registered PopulationOver 65s% over 65s Cluster 129,9896,27421% Cluster 256117618611% Cluster 340,1846,88617% Locality - Kingswood Registered PopulationOver 65s% over 65s Cluster 449,3758,73118% Cluster 546,2618,68219% Cluster 6 (ELF)34,1396,33619%

14. What are we doing?  We want to think about the way services operate from the perspective of the individual.  To do this we are using a concentric circles model with the individual in the centre. Our Approach  The image illustrates how close the support is to the individuals, with more remote services (e.g. hospitals) further away.

15. What are we doing?  We are realigning our community healthcare resources around groups of GP practices to provide Intensive community support  This includes – Community Matrons, District nurses, Emergency Care practitioners, Rehab. Therapists  New roles and services – Active ageing and the “ward clerk”  Discussion with partner agencies including the Council and AWP to align their community based staff Our Approach -

16. What are we doing?  We have started piloting our approach in the Cluster that covers Downend, Emersons Green and Frampton Cotterell.  This includes the Emersons Green, Leap Valley and Frome Valley GP practices.  It covers a population of 34,139 with 6,336 over 65 year olds Our Approach

17. What are we doing? Measuring Success in South Gloucestershire in 2015-2016 – BCF Ambitions Non-Elective Admissions (general & acute) 5% reduction in admissions per year. (c.1000) approx. 130 fewer in ELF Cluster* Admissions to residential and care homes 2% reduction in admissions per year. (c.8) approx. 1 fewer in ELF Cluster* Effectiveness of reablement 92% of >65s still at home 91 days post discharge (currently 89%) approx. 2 more in ELF Cluster* Delayed transfers of care 4% reduction in adult DToCs. per year (c.250) approx. 34 fewer in ELF Cluster* Patient / service user experience Ambition – To be confirmed Injuries due to falls in people aged 65 and over Reduction in the rate of falls from 19 to 17 per 1000 population. approx. 68 fewer in ELF Cluster* *approximations are relative to the ELF Cluster and its targeted population Linking with the BCF

18. What else could we do? What else could we do to harness the power of collaborative care and support with other partners?