Event cluster presentation

1. Integration of
health and social care
in Wokingham borough
Have
your say

2. Today’s Agenda
• Hear more and
contribute to our plans
on integrating care
across Wokingham
Borough
• Look at one particular
scheme in more detail;
grouping services
around neighbourhoods
Today’s session will include
• A presentation from
Wokingham Borough
and the CCG
• A chance to see the latest
film describing our plans
• Group discussion
considering important
questions around how we
take the plans forward

3. Integration of health
and social care
- Stuart Rowbotham and Katie Summers

4. Why integrate?
• What you have told us
at Call to Action events
• Care for people as
individuals
• Changing population
• Financial sustainability
People with more than one
long term condition, often
with complex needs, may be
visited or contacted by a
number of different people
from different departments in
different organisations who
may not fully understand the
individual’s overall needs.

5. Five Year Forward View
• New models of care and joint commissioning
• A stronger role for the voluntary sector
• Valuing the role of District General Hospitals
• Transformed primary care
• Greater emphasis on improving public health
• People more in control of their own care
• Better use of innovative technology

6. Implementation of Care Act
• Implementation of new eligibility criteria and
assessments
• New entitlement to services for self-funders and
carers
• Information and advice
• Prevention
• Statutory Safeguarding Board

7. The Better Care Fund
• Designed to deliver more services provided in
the community, developed in partnership
between health and social care
• From April 2015
• Pooled budget £9.5m
• 9 Schemes, including neighbourhood clusters to
enable local services to work more closely
together

8. • Care provided by multidisciplinary, multi-agency community teams.
• ‘Generic workers’ providing routine straightforward nursing, rehabilitation
and personal care.
• Care managers who will act as an interface between an individual and their
care team and coordinate the care for that individual.
• Sharing of staff, facilities and information.
• Identification of people who are not yet in crisis but at risk of getting to crisis
point.
• Single points of contact will have replaced multiple information sources
about what health and social care services are available locally.
• People will be supported in managing their own long term conditions.
• There will be growth in personalisation to ensure that care packages meet
individual people’s needs and choices.
• Funding increasingly being managed through personalised budgets
What could success look like?

9. A new chapter:
Sam’s story in Wokingham

10. Supporting Sam
through
Neighbourhood
Cluster Teams

11. Why Neighbourhood
Cluster Teams?
Local people have called for
“More joined up services ”
“Telling our story once”
“Better access to local
services”
Local professionals are asking for:
Local named contacts
Service coordination
Shared decision-making
A changing population
Financial challenges
Need to value and develop local people and organisations

12. What might a Neighbourhood
Cluster look like?
• Population of 50 - 60,000
• A central point (e.g. library, GP practice)
for some services
• Certain services use cluster
as catchment areas for caseload
• Named contact(s), shared
between teams within clusters
• Shared care plans

13. Benefits of
Neighbourhood Working
for residents for the health and social care system
Promotes preventative, social
approach
Earlier interventions, reducing risk
of non-elective hospital admission
Continuity of care
Flexible deployment of resources,
breaking down unnecessary
organisational barriers
Contributes to ambition that
residents tell their story only once
Reduction in duplication of tasks
Services are more local
Improved integration, including
with the community and voluntary
sector
People are treated as individuals Shared care plans, reviews etc.

14. Neighbourhood Geography
• Loddon Vale
• Parkside
• Woodley
• Wilderness
• Twyford
• Wargrave
61k rising to 64k
• Brookside
• Swallowfield
• Shinfield
41k rising to 59k
• Woosehill
• Wokingham MC
• Burma Hills
• Finchampstead
• New Wokingham
Road
59k rising to 70k
Practices and changes in population from now to 2022
(taking into account new housing developments)

15. Developing
Neighbourhood Clusters
EAST WEST NORTH
Development of Cluster Integration
SMARTER working
Focus on priorities e.g. GP-social care interface
TRIAL OPTIONS IN EACH CLUSTER
Community &
Voluntary Sector
coordination
Urgent
Care
Generic
Primary Care Nurse
e.g. wrap-round
services for
identified clients
e.g. hub/spoke model
for delivering
extended access
combination of practice
and community
nursing roles

16. Path for
Cluster development
2015 2016
Jan Apr Jul Oct Jan Apr Jul Oct
Development
of options
Trial option
in each cluster
Possible
roll out
across
clusters
Development
of business case
EVALUATION
CONSULTATION AND ENGAGEMENT

17. Time for discussion
1. Cluster Working
2. Community and Voluntary Sector Coordination
3. Extended GP Access
4. Self Care / Primary Prevention
5. Anything else...?

18. or follow us
@WokinghamCCG
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“Wokingham Have Your Say”
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23rd – 27th March