Frimley Health and Care Integrated Care System Our

Frimley Health and Care Integrated Care System

Our Journey: 2015 -16 2015 2014 2013 2012 2017 Frimley Health and Care Vanguard Programme driving real improvements for patients Risk Share contract with main acute provider CCG Five Year Strategy developed with partners Establishment of CCGs, shared leadership of our system change projects Kings Fund and re-launch of system work with common aims and shared objectives System Transformation Board Page 2

The journey continues: Clinical Leadership Engagement Vanguard Primary Care transformation Self Care and Prevention Mental Health ICS

The changing NHS landscape From: § Vanguards and lots of CCGs § Independent assurance of providers and commissioners To: § Building successful well led integrated systems § Collective responsibility § Blurring boundaries between commissioning and provision § Integrated Care Systems § Systems changing at different paces, in different ways, different approaches

Population of 800, 000 people in East Berkshire, North East Hampshire and Farnham and Surrey Heath CCG’s. Involves 30 statutory bodies. Includes Local Authorities, CCGs, provider Foundation Trusts and others

Creating healthier communities Your Local Authorities and local health organisations are working together as the Frimley Health & Care System to provide you with a joined up health, care and wellbeing system. This means you will receive the right care at the right time and in the right place. This means you and your family will: • Be supported to remain as healthy, active and independent as you can be • Know who to contact if you need help and only have to tell your story once • Have easier access to information and services • Work together with a care and support team to plan and manage your own care • Access urgent or emergency care more easily closer to home • Treated in the best place for your needs • Increase your ability and confidence to take responsibility for your own health, care and wellbeing • Be confident that your care is provided in the best possible way.

Workstream Aims: • Prevention and self-care – ensuring people have the skills, confidence and support to self-care and to stay well • Integrated care decision-making – developing integrated teams of multi-disciplinary practitioners providing single points of access to services such as rapid response and re-ablement • GP transformation – laying foundations for a new model of general practice provided at scale to offer a wider range of services in the community, including development of GP federations to improve resilience and capacity • Support workforce – supporting the care support workforce so that it is fit for purpose and offers good career opportunities across the system • Care and support – transforming the social care support market and improved management of the market by health and social care working more closely together. Helping to make the best use of the money available across the Frimley Health and Care system and better plan for the future care support needs of local people. • Reducing clinical variation – ensuring that the population has access to the same high quality of services across the system wherever they live • Shared care record – helping people to tell their story once by implementing a shared care record that is accessible to professionals across the footprint

Developing services across health and care:

Our system on aplan page: 2018/19 System on a page Priority 1: Making a substantial step change to improve wellbeing, increase prevention, self-care and early detection Local Priority 2: Action to improve long term condition outcomes including greater self management & proactive management across all providers for people with single long term conditions 1. Prevention & Self-care: Ensure people have the skills, confidence and support to take responsibility for their own health and wellbeing 2. Integrated care decision-making: Develop integrated decision making hubs to provide single points of access to services such as rapid response and re-ablement 3. GP Transformation: Lay foundations for a new model of general practice provided at scale, including development of GP federations to improve resilience and capacity. 4. Support Workforce: Design a support workforce that is fit for purpose across the system Priority 3: Frailty Management: Proactive management of frail patients with multiple complex physical & mental health long term conditions, reducing crises and prolonged hospital stays 5. Care and Support: Transform the social care support market including a comprehensive capacity and demand analysis and market management Priority 4: Redesigning urgent and emergency care, including integrated working and primary care models providing timely care in the most appropriate place 6. Reducing clinical variation: Reduce clinical variation to improve outcomes and maximise value for individuals across the population. Priority 5: Reducing variation and health inequalities across pathways to improve outcomes and maximise value for citizens across the population, supported by evidence Cross cutting Programmes National ‘must do’s’: Primary Care, Urgent and Emergency Care, Referral to treatment times, Cancer, Improving quality Financial sustainability Development of high quality STP Transformation Initiatives Urgent & Emergency Care Mental Health & Learning Disabilities Maternity Children & Young People Cancer Enablers Workforce . Enablers National Five Year Priorities 7. Shared Care record: Implement a shared care record that is accessible to professionals across the STP footprint. Communications and engagement Analytics Estates Digital & Technology

Next steps for engagement: § Continued engagement on priorities with local communities § Five to ten year national plan engagement programme § North East Hampshire and Farnham events plan