1. Developing an Integrated System in Cambridgeshire and Peterborough
Presentation to Hunts System
June 2015
Gill Kelly, CCG – Joint Integration Team

2. Agenda The vision for delivery: 10 features of an integrated system
The delivery mechanisms: Better Care Fund and the CEPB Programme
Programme outcomes and system benefits
Next steps

3. The 10 features of an integrated system:
Planned programmes that help people to age
healthily
2. A set of triggers of vulnerability which generate a planned response across the system
3. A universal network helping older people and their families to find high quality information and advice
4. An aligned set of outcomes
5. An integrated front door and agreed principle of ‘no wrong door’
6. Shared assessment process, and information sharing between health, social care and other key partners
7. A shared tool that describes levels of vulnerability
8. Multidisciplinary team (MDT) approach
9. Joint commissioning and aligned financial incentives
10. Co-location
A key organising principle: the need to develop this system in a way that is based upon the real experiences and needs of older people and their families and carers rather than on organisational arrangements.
System wide sign up to these from CEPB / BPEPB
Driver for programme design and implementation

4. The Better Care Fund
Single pooled budget for health and social care services to work more closely together in local areas from April 2015.
Cambridgeshire: £37.7m
Peterborough: £12m
Aims to put people at the heart of health and social care (particularly the most vulnerable), address demographic challenges, improve services and reduce costs
BCF = part of the transformation agenda in Cambs and Peterborough

5. A system based approach to improving outcomes for older people
5 whole system projects that will deliver outcomes in conjunction with key partners: UnitingCare Partnership, GPs, acute trusts and the voluntary and community sector
Alignment of system wide transformation initiatives, and associated governance structures and mechanisms
Evidence based improved outcomes and benefits for people, and for organisations that deliver care and support to older people
Complement and support delivery of the Older Peoples and Adults Community Services (OPACS) outcomes framework

6. Five Key Integration Projects
Cambridgeshire Health and Wellbeing Board & Peterborough Health and Wellbeing Board
Cambridgeshire Executive Partnership Board (CEPB) Programme
Projects
Data sharing*
Interfaced IT systems
Information governance protocols
Data sharing models and practices
7 day working
Discharge Planning
Independent, health and housing providers
Admission Avoidance
Person centred system
Integrated Neighbourhood Teams*
Risk Assessment tool*
Integrated Assessment & accountable professional*
Customer journey
Information and communication
System wide information provision / co-ordination*
Integrated system wide ‘front door’*
Ageing healthily and prevention
Public Health programmes*
Triggers and pathways*
Strong & supportive communities
Planning for growth

7. Programme outcomes
Hospital staff will see fewer frail and elderly patients
Hospital discharge will be made easier
Patients and service users will experience more joined up, sensible care and support plans that are centred around their individual needs and wishes
Professionals will be aware of one another's interventions
There will be a common way of identifying people at risk of ill health
People will be empowered to remain healthy and independent
Hospital staff will see fewer frail and elderly patients because more care and support will be provided in community care settings, co-ordinated effectively through multi-disciplinary working and Integrated Neighbourhood Teams.
Hospital discharge will be made easier through the expansion of 7 day working for related health, social care and community services and within the residential and nursing home sector.
Patients and service users will experience more joined up, sensible care and support plans that are centred around their individual needs and wishes and wherever possible, enable them to remain living within the community.
Professionals will be aware of one another's interventions through effective and timely information and data sharing mechanisms.
There will be a common way of identifying people at risk of ill health, hospital admission or those deemed as ‘frail’ through shared assessment and risk stratification processes across the system.
People will be empowered to remain healthy and independent, and to make informed choices about their own care and support through the provision of good quality, accessible information and simple access to the system, and through the provision of community based opportunities that improve health outcomes and enable people to retain their independence.

8. 2015/16 goals (Cambs) 1.0% (516) reduction in non-elective admissions;
3.5% (974) reduction in the numbers of delayed transfers of care;
8.2% reduction in permanent residential admissions
Greater provision of community based health and social care services to facilitate discharge and prevent unnecessary admissions
*To be reviewed

9. Looking ahead – next steps:
Implementation of projects now underway
More engagement with CCG Local Health Systems and acute trusts
Local delivery via UnitingCare, Integrated Care Boards, System Resilience Groups, bespoke project groups
Joint Integration Team will oversee implementation, alignment and engagement

10. Discussion Questions
How and where should we engage more fully with you?
Where can this work build on what is already happening?
Where are the gaps?