1. Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson Bringing clinical leadership to local health needs www.aylesburyvaleccg.nhs.uk Creating a Coherent Common Vision for Integrated Care Dr Graham Jackson, Clinical Chair AVCCG On behalf of Aylesbury Vale and Chiltern CCGs

2. Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson Bringing clinical leadership to local health needs www.aylesburyvaleccg.nhs.uk Everyone working together to provide high quality personalised care, to help keep Buckinghamshire people happy and healthy (optimising value from our collective efforts) Our vision: Healthy Bucks Leaders

3. Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson Bringing clinical leadership to local health needs www.aylesburyvaleccg.nhs.uk Our Community Buckinghamshire - population 500k, wealthy county with better than average health outcomes and longer life expectancy Considerable variation underlies these figures Most common cause of death is heart disease and stroke (31%) Long term conditions account for 70% of health and social care spend Health receives 17% less than average through funding formula

4. Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson Bringing clinical leadership to local health needs www.aylesburyvaleccg.nhs.uk Our Health & Social Care Stakeholders Aylesbury Vale and Chiltern Clinical Commissioning Groups Buckinghamshire County Council –(with 4 district councils) Buckinghamshire Healthcare NHS Trust –integrated community, acute and specialist care Buckinghamshire Urgent Care –out of hours primary care and Minor Injuries Unit at Wycombe Oxford Health NHS Foundation Trust –providers of mental health services to Buckinghamshire South Central Ambulance Service

5. Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson Bringing clinical leadership to local health needs www.aylesburyvaleccg.nhs.uk What is Integrated Care? Professionals and services working together as a ‘team around the patient’ (National Voices, A Narrative for Person-Centred Coordinated Care, March 2013)

6. Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson Bringing clinical leadership to local health needs www.aylesburyvaleccg.nhs.uk Meet Ethel Age 78 years, diagnosed recently with Dementia ‘Prisoner at home’; husband at end of tether Falls out of bed one evening when neighbour is sitting for husband (who’s shopping at Tesco – his only chance to go)

7. Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson Bringing clinical leadership to local health needs www.aylesburyvaleccg.nhs.uk Ethel’s urgent care experience Neighbour calls 999 Admitted to Dementia Care Home Arrives in A&E 3 hour wait Sprained ankle, no fracture Drs have no idea of Ethel’s usual cognitive ability No transport back to Winslow at midnight - admitted Three week stay (average for dementia patients) decreased mobility, increased confusion so increased medication Ambulance performance based on time to respond – need to get Ethel to hospital and move to next patient, no incentive to keep her at home Hospital fined for A&E waits over 4 hours, increased funding for admission rather than just A&E attendance, no funding for transport home Dementia care home happy for income, early admission means quicker loss of independence. Ongoing cost to Local Authority and to family

8. Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson Bringing clinical leadership to local health needs www.aylesburyvaleccg.nhs.uk What Ethel’s experience should have been Early diagnosis, support networks set up for Ethel and her husband Home with additional support for two weeks Arrives in Minor Injuries centre Ethel remains at home for a longer period of time, with maximum independence. Husband happy to continue care as he has regular breaks and robust local support Ambulance has seen patient notes and transports Ethel to GP led unit for check x- ray. Dr aware of Ethel’s cognitive ability and knows to avoid admission if at all possible Transport organised home Social services assessment following day Exercise programmes on you tube to maximise mobility Physio follow up booked at local community hospital Community Prevention worker, Alzheimer's society, regular breaks for carer husband. Weekly music therapy and maximum independence in a Dementia friendly Town where people are trained to support dementia sufferers

9. Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson Bringing clinical leadership to local health needs www.aylesburyvaleccg.nhs.uk Existing examples of Integrated Care in Bucks

10. Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson Bringing clinical leadership to local health needs www.aylesburyvaleccg.nhs.uk Next steps Enhancing self care and long term conditions management High quality information, education sessions, expert patient programmes, support groups and online networks. Shared decision making, increased use of technology and population outcomes commissioning. A tailored approach for higher risk groups Understanding our populations and the different health challenges they face Prescribing lifestyle changes social prescribing that requires changes in behaviour, front line staff raising lifestyle issues at every opportunity, signposting to support services Addressing mental wellbeing needs for patients and carers including advice on staying healthy and being emotionally resilient

11. Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson Bringing clinical leadership to local health needs www.aylesburyvaleccg.nhs.uk Establish shared leadership; develop a persuasive vision Create time and space to develop understanding and new ways of working Bottom up as well as top down approach Welcome to Lesley Perkin as our Programme Director for Integration! Share information Use the workforce effectively Innovate, innovate, innovate! Healthy Bucks Leaders is working to the Kings Fund ‘16 steps to integration’ which include: Next steps

12. Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson Bringing clinical leadership to local health needs www.aylesburyvaleccg.nhs.uk 1.We are learning organisations – and need educational support 2.We work to evidence based practice 3.We want to innovate – but with academic rigour to ensure we do this properly for our patients Why we need an Institute of Integrated Care