South Gloucestershire Clinical Commissioning Group Governing Body Meeting

Transcription

1 South Gloucestershire Clinical Commissioning Group Governing Body Meeting Date: Wednesday 28 October 2015 Time: 1pm Location: Emerson s Green Village Hall Agenda item: 6.5 The CCG s Operational Plan 2015/16 Mid Year Review 1 Purpose To brief the Governing Body on progress towards delivering the CCG s operational plan in 2015/16. 2 Recommendations The Governing Body is asked to note the good progress made during the last 6 months. 3 Background This paper provides a summary of progress in delivering the commissioning programmes outlined in the updated operational plan agreed by the Governing Body in March 2015 for this financial year. It is not a comprehensive review of all commissioning initiatives contained in the integrated plan, but highlights progress in delivering the priority initiatives agreed for this year. This paper also excludes a detailed assessment of progress towards the consistent delivery of the NHS constitution standards that relate to provider performance, as this is covered separately in the monthly performance report for the Governing Body. 4 Discussion of issues The attached summary of progress towards the CCG s priority initiatives for this financial year brings out the breadth and ambition of the CCG s work programmes. These include: Improved urgent and emergency care services for patients The work of the System Flow Partnership chaired by Dr Ann Sephton is overseeing a major programme of work to improve services via its 4 work streams for admission avoidance, improving patient flow within North Bristol NHS Trust (NBT), enabling discharge, and frail and elderly care. This has led to much improved system working and has delivered significant progress towards the sustained achievement of the NHS constitutional standards for urgent and emergency care. Transformation of community services The transformation of community services has been another key theme for the CCG. It has continued this financial year to be a focus for both additional investment and commissioning support expertise. Work to embed the new model of care for community health services is continuing, with a pilot underway for a multi-disciplinary team approach at cluster (locality) level as well as with individual practices. There has been a significant expansion in community South Gloucestershire CCG Leading you to Better Health Clinical Chair: Dr Jon Hayes Chief Officer: Jane Gibbs

2 capacity, enabling many patients to be discharged from hospital to recover closer to home as soon as they are no longer in need of acute hospital care. Good progress has been made towards establishing the new community specialist service for diabetes care, which is due to start in November The foundations for a community service providing specialist respiratory care are also in place. While progress has been slower than originally hoped, significant benefits are expected for patients in the future from the establishment of an integrated community hub closely linked to consultant-led care based in Southmead hospital, which will form the basis for a future transformation of community services for patients with respiratory conditions. Finally, a non-competitive procurement process is underway for the commissioning the development of community rehabilitation service hubs and associated facilities on the Frenchay and Thornbury hospitals sites. The Governing Body is due to receive a report next month on the results of the due diligence stage. Transforming health care for care home residents The CCG commissioned a range of service improvements for care home residents over the last financial year, including enhanced in-reach support from community and primary care services. Building on the success of this work, 2015/16 has seen an expansion of the successful specialist service provided by Avon and Wiltshire Mental Health Partnership NHS Trust for challenging patients (particularly those with dementia). A further new service development for care home residents this year has been the appointment of a dedicated care homes pharmacist to review medications and reduce wastage, who is also becoming involved in wider safeguarding and quality issues. While not yet comprehensive in coverage, the enhanced package of health care services for care home residents together provides a model of care that reflects closely the new care model for care homes outlined in NHS England s Five Year Forward View. Connecting Care The Bristol, North Somerset and South Gloucestershire (BNSSG) Connecting Care programme was last month named as the overall winner of the EHI Awards The programme is enabling better information sharing between local health and social care organisations so that care can be joined up, improving patients experience and supporting greater efficiency. The Stage 2 portal, which will deliver a shared care record for securely sharing patient data, went live in September This is a significant development which will facilitate the CCG s vision for coordinated care in the future. Communications, patient engagement and involvement Overseen by the Improving the Patient Experience Forum (IPEF), there has been a great deal of work by the CCG to ensure patients, stakeholder organisations and members of the public are involved in shaping service developments. The consultations underway for the reprocurements of patient transport and children s community services reflect the learning from previous projects (including for minor injuries services), with a growing maturity and confidence in approach to the CCG s engagement activities. Communications have also improved, with a review undertaken of the website to improve access to publically available information. The Governing Body will also wish to recognise the work of the CCG, in partnership with colleagues in Bristol CCG, to secure at short notice an interim provider for children s and young people s community health services from April This has been undertaken alongside the major procurement process for a long term provider of the services. 2

3 5 Financial implications The programme of work being undertaken by the CCG is designed to enable the organisation to achieve its financial plan. Monitoring of progress within the CCG is well established, with regular detailed reports being provided to the Clinical Operational Executive. 6 Legal implications Not applicable. 7 Risk Implications The CCG has a number of significant risks which are being managed as part of the CCG s assurance framework. 8 Implications for health inequalities The CCG s programme of work is designed to reduce health inequalities within the population served by the CCG, with a particular emphasis on improving access. 9 Implications for equalities (Black and Other Minority Ethnic/Disability/Age Issues) The programme of work is designed to promote equalities within the population served by the CCG. 10 Consultation and Communication including Public Involvement Not applicable 11 Appendices 1. Operational plan 2015/16 - Mid year update Prepared by: Louise Rickitt and Kirsteen Akhurst Presented by: Louise Rickitt 20 October

4 Operational Plan 2015/16 Mid-Year Update Service Change Priority 1: Improve the utilisation of facilities in Yate and Cossham, increasing the availability of out-patient clinics Develop a community eye health services as an alternative to hospital based services Review and improve musculoskeletal services Service Change Priority 2: Secure achievement of NHS constitutional standards for South Gloucestershire residents A better experience of routine out-patient services Discussions underway as part of contract management with NBT. Evaluation completed of the pilot Community Optometry Service, based in Kingswood. The service is valued by both service users and GPs, and has had a positive impact on the number of referrals to secondary care. The procurement for a community optometry service for South Gloucestershire is now underway. The referral pathway for patients with low back pain has been revised to streamline triage and ensure patients access the right treatment at the right time. Staffing requirements have been reviewed, and additional staff recruited to support the triage service and reduce waiting times. An effective and efficient hospital service providing first class medical care The CCG has continued to work intensively with NBT and partners via the System Flow Partnership (chaired by the CCG s Deputy Clinical Chair). As a result, there has been significant progress towards the sustained delivery of the constitutional standards for urgent and emergency care. This improvement has been supported through an integrated and embedded recovery plan, which has been owned and delivered by all members of the SFP. The plan has been developed through continuously capturing lessons learnt over 14/15 and in particular from the Onwards Together Week in March In addition, the plan has also been supplemented with advice and guidance from national best practice. The achievement of access standards for planned care continues to be challenging, reflecting gaps between capacity and demand in a number of specialties: neurology, neurosurgery, neuropsychiatry, renal, urology and gastroenterology with a return to constitutional standard forecast by the autumn 2016 at the earliest. The Planned Care Steering Group monitors performance of all providers on a monthly basis using the planned care dashboard to highlight specialties that are under-performing against constitutional standards and inform

5 actions to help improve performance. Trauma and Orthopaedics remains the most challenged specialty and the CCG is leading a work plan to maximise system-wide capacity and reduce demand. A review of the Individual Funding Request system in place has demonstrated that the policies produced by the IFR team and agreed via the CPRG route are robust both in terms of quantity and quality, minimising the risk of a successful legal challenge and over performance of activity in the key treatment areas. Working with partners (NHS providers, South Gloucestershire Council, and other CCGs), improve the patient flow thorough local hospitals for both planned and unplanned care For cancer the main focus both locally and nationally has been on improving performance against the 62 day referral to treatment standard which requires 85% of patients to be treated within this timeframe. UHB and NBT have submitted action plans and revised trajectories describing how this standard will be delivered by the end of the financial year at the latest. The System Flow Partnership acts as a multi-organisational urgent care working group which is responsible for ensuring delivery against key nationally mandated and locally agreed performance standards. Monthly meetings are attended by senior managers and/or clinicians from: South Gloucestershire and Bristol CCGs, South Gloucestershire Council, City Council, Sirona Care & Health, Bristol Community Health (BCH), Avon Wiltshire Mental Health Partnership NHS Trust (AWP), Brisdoc, North Bristol NHS Trust (NBT), South West Ambulance Service Foundation Trust (SWASFT), Care UK (NHS111), South West Commissioning Support, NHS England. The current operational priority is to implement the integrated North Bristol System Recovery Plan, focussing on 4 key areas: admission avoidance, improving patient flow through the Trust (NBT), enabling discharge, frail & elderly care. These 4 work areas are managed by multidisciplinary, cross organisational teams, which are responsible for ensuring progress of all projects in their areas. This structure has enabled significant progress to be made across the four priority work areas, by: maximising utilisation of primary and community services to reduce hospital attendances and admissions; improving processes at the front door to improve flow through the emergency zone at Southmead Hospital; improving the management of inpatients to shorten hospital based treatment and recovery pathways; improving discharge processes, and bolstering community services to ensure patients can be discharged from hospital as soon as they are no longer in need of acute hospital care; increasing the use and efficiency of ambulatory care pathways provided by primary and secondary care teams. 2

6 Effective systems for quality assurance and safeguarding, in place for all providers including individually funded health care packages Improvements secured to date in 2015/16 include: Greatly improved A&E performance, resulting in delivery of 95% 4 hour standard in June and July; Reduction in average number of A&E attendances, from over 240 per day in April to around 225 per day in August; Reduction in the average number of ambulances conveying to Southmead Hospital; Reduction in the number of ambulance handover delays over 15 minutes, from around 30 per day in Q4 of 2014/15 to around 20 per day in Q1 and Q2 of 2015/16; Improvements in number of discharges before 10am, and increased numbers of weekend discharges; Reduction in the number of patients in hospital with length of stay over 14 days, from over 320 in early April to around 260 in August. The Nurse Director and Deputy Nurse Director are members of both the adult and children safeguarding boards, and chair the quality monitoring sub groups of both of these boards. We work closely with our partners across the health and social care system to ensure that the process of safeguarding for both adults and children is safe, effective and of high quality and that statutory requirements are met. Service Change Priority 3: Continue implementation of urgent and emergency care strategy, working closely with key partners. Priorities for 2015/16 include: GPSU service at Southmead Hospital Community based minor injuries services Admission avoidance Enabling discharge We also work closely with all of our providers to ensure that there are effective quality monitoring systems in place. This is carried out through local quality sub groups, contract, performance and quality meetings and issues are escalated where further interventions are necessary. Where possible quality key performance indicators are reviewed with providers. Where risks are highlighted then risk mitigation is discussed and actions jointly agreed. Quality assurance visits are also carried out. Transformed urgent and emergency services, including in primary care and other settings GP support team service now in place at Southmead Hospital. Since April 2015, it has: - taken over responsibility for receiving telephone calls from local GPs who are considering admission or specialist assessment of medical patients. Operating hours are currently Monday to Friday, 8am to 6.30pm. - been seeing patients who have attended A&E and deemed to be appropriate for a primary care consultation. Patients are seen by an Advanced Nurse Practitioner who is supported by an on-site GP. The ANP may redirect patients to a more appropriate care service, provide care and treatment, or direct the patient back to the emergency department. Current operating hours are Monday to Friday, 12pm to 8pm. 3

7 Frailty service Starting in September, the team now operates alongside acute teams in the Ambulatory Emergency Care area to assess and treat patients with a primary care approach to risk. Minor Injuries Service. Plans developed for a locally enhanced service (LES) agreement for GP practices in South Gloucestershire to provide a defined range of minor injury services to their registered patients. The service is being proposed as a pilot. The model was approved by the CCG Governing Body in September. Training will take place in Q3 and Q4 prior to its launch in April Enabling Discharge. Good progress has been made including: improved systems for identifying delayed transfers of care; the design of an Integrated Discharge Service within the hospital; pilots underway for the Discharge to Assess pathways, with plans in place to increase this offer to support the NBT system in October. Work is now focusing on planning for and implementation of the stepped change with all partners prioritising their work around removing barriers, changing culture and ways of working to improve the efficiency and effectiveness of discharge processes prior to winter Service Change Priority 4: Review respiratory care pathways and develop an integrated respiratory service Community Frailty Service The new community frailty service is on track for implementation in October 2015 as planned. The service has successfully recruited 2 GPs with Special Interests to lead the service, who will be supported by a multidisciplinary team. A programme of patient and public involvement has been undertaken, which has highlighted the need to ensure this is a holistic service which focuses on the individuals overall wellbeing, and works in partnership with carers, this has shaped the delivery model due to start from October. Better community adult health services, especially for the elderly A project team has been established, including clinical and managerial representation from both Sirona and North Bristol Trust. A review of the home oxygen pathway is currently underway, which has been identified as a priority together with the provision of an integrated community hub through the Hot Clinic. Additional work 4

8 Commission a community diabetic specialist nurse service Continue with the development of End of Life Care Co-ordination Services, including a single point of access and community care within 24 hours. streams including pulmonary rehabilitation, early supported discharge, education and prescribing scheduled for the latter half of the year. Good progress has been made in establishing a community diabetic specialist nurse service, with successful recruitment to the lead DSN role and Band 7 DSN, and a soft launch of the service commencing during November The service model for End of Life Care Coordination has been designed with broad stakeholder engagement and, following public consultation, the service specification has been signed off by the Clinical Operational Executive. Recruitment of staff is underway and service launch is on track for October Service Change Priority 5: Improved mental health services, and better access to physical health services for people living with mental health problems Secure achievement of new national standards for improving access Re-procurement of IAPT (talking therapies) services Undertake a full review of inpatient services provided by AWP Service Change Priority 6: services The CCG is currently meeting the new access targets for IAPT. The new target for early intervention in psychosis (from April 2016) also currently appears to be met in South Gloucestershire, however commissioners are working with AWP to understand changes that may be required to the operating model to ensure this is achieved over the longer term. Following agreement by the Governing Body the CCG has paused the procurement process for IAPT services and is working with existing providers and the University of Chester to design and pilot an improved operating model for IAPT services. The first test and learn cycle will start in October in cluster 5, and will involve an initial face to face assessment and therapy provided by a senior clinician in the patient s GP practice (or a practice that is local to them). A contract variation is currently being negotiated to enable this to take place. AWP are working through the acute care pathway improvement work which has been split into 3 phases, the first two of which are internal to the Trust. The Trust plans to engage commissioners and other partners (e.g. South Gloucestershire Council) from November in the main work which is due to run over an 18 month period. The aim of which is to reduce length of stay, improve quality of care and reduce the number of patients admitted to beds out of area. Progress to date has been limited. Better community health services for children and young people, including mental health 5

9 Improve the capacity and performance of mental health services for children and young people During 14/15, the CCG was able to identify additional investment to support the development of mental health services for children and young people. This has been targeted at three schemes: The creation of an open-access counselling service for children aged The introduction of two Primary Mental Health Specialist posts, employed by the CAMHS service but colocated and embedded within the Council s Youth Intervention and Support Service teams Investing in additional Consultant Psychiatric time within the Tier 3 (specialist) CAMHS service Service Change Priority 7: working with older people Continue to work with care homes, enhancing support available (GP and pharmacist) and skills for caring for people with dementia All three schemes are now in place, adding significant capacity to the local mental health system for children and young people. The specialist CAMHS service has historically been under considerable pressure and, as a result, waiting times for new referrals had increased. This was reported through our contract monitoring and performance management processes, and an action plan was agreed with the provider. This has been very successful. The team has worked through the waiting list and brought South Gloucestershire waiting times back into line with contractual expectations. Better dementia awareness across South Gloucestershire, and improved skills of staff The Care Home Liaison service provided by AWP supports care homes to care for people whose behaviour is challenging, many of whom will have dementia. This year the CCG has invested to expand the team, enabling them to work in all care homes in South Gloucestershire and to do more staff training. Additional capacity has also been funded to enable the service to check whether more people in the care homes have dementia, to ensure care is appropriate and help us achieve the national diagnosis target. A CCG Care Homes pharmacist has been recruited and started in September 2015 to undertake medication reviews and provide medicines management support to care homes. 1.6FTE Pharmacists have been recruited into Sirona to support the Frailty Service and deliver medication review for housebound patients. These pharmacists also start in post on 14 th Sept Both the Care Homes and Sirona Pharmacist projects have evaluation plans in place which include reporting on financial savings through changes to prescriptions and quality aspects using a risk stratification tool which 6

10 Service Change Priority 8: hospital Continue with the implementation of the new model of care, focusing on capacity available within the community Commission the development of infrastructure for services to be provided at Thornbury and Frenchay Cross-cutting Priority 9: In partnership with NHS England, support the development of new primary care provider models identifies prevented admissions. Financial savings information will be sent to COE on a monthly basis and more detailed reports will be submitted quarterly detailing patient impact/avoided admissions. PPI has been included in both schemes as appropriate. Transformed rehabilitation, recovery and reablement services, greatly reducing time spent in Good progress has been made this financial year. Work has continued on testing the 3Rs model using existing services as part of Phase 1 of the programme. We have reviewed community rehabilitation provision, including the current provision of community rehabilitation beds, and the development of plans by Sirona to take over the management of one of the rehabilitation wards at Elgar House. We have proactively sought and reviewed feedback from service users and carers to ensure their views and needs are incorporated into the development of the model. Building on the Phase 1 work, in March 2015 the CCG Governing Body approved Phase 2 of the programme to embed the model of care on a long term sustainable basis. It was agreed that this would be taken forward as a non-competitive tender with current providers NBT and Sirona, subject to appropriate due diligence reported to the CCG Governing Body (scheduled for November 2015), and with a view to developing community capacity on preferred sites at Thornbury and Frenchay. Significant work is underway to take this forward, including planning the procurement process and agreeing a detailed Statement of Commissioner Requirements against which provider proposals are being tested. Currently, the procurement is mid-way through the detailed due diligence stage with the aim of reporting to the CCG Governing Body in November 2015, to enable a final decision to be made to enable delivery/implementation of the model in 16/17. Underway. See above. Primary care services fit for the future providing better access to more services The CCG continues to support practices that wish to explore new provider models, and facilitated a workshop in May which was led by a number of practices. The CCG has provided opportunities to practices to consider how they might work collaboratively as provider organisations, including: 7

11 Primary care support seven days a week for patients with complex needs or approaching end of life Pilot a new primary care frailty service, linked to the community-based rapid assessment clinic provided by geriatricians Cross-cutting Priority 10: Continue integration programme for health and social care services, working with South Gloucestershire Council under Better Care Fund. To include implementation of cluster model - formation of MDT meetings for clusters of practices; and - inviting as part of the 2016/17 planning round ideas from groups of practices for pilots to test different ways of collaborative working. This builds on the success of this approach last year which has led to the new Community Frailty service pilot. In September the first meeting of the shadow Joint Co-commissioning Committee took place with NHS England. The service model for End of Life Care Coordination has been designed with broad stakeholder engagement and the service launch is on track for October The new community frailty service is on track for implementation in October 2015 as planned. The service has successfully recruited 2 GPs with Special Interests to lead the service, who will be supported by a multidisciplinary team. Transforming care planning and care coordination The Happy, Healthy and at Home Cluster integration project is a key part of the South Gloucestershire Better Care Fund programme and is dedicated to developing a support model within South Gloucestershire in which local people, their communities, health providers, social care and the voluntary and private sector all work together in order to offer a comprehensive and holistic package of health, care and wellbeing to all in need and to encourage and support healthy lifestyles to enable people to stay healthier for longer. The project builds on existing services to create an integrated approach, and since April significant work has been undertaken to continue to develop the approach and move things forward. Engagement of key organisations across the health and social care system (and including the community and voluntary sector) has been carried out in partnership with Building Health Partnerships in order to comprehensively map existing services and offers, along with current projects and programmes of work. This has resulted in the development of a draft road map for integration to 2020 and the agreement of a high level model for connecting people and professionals in each cluster by bringing services together and enabling easy access to information about what is available/on offer. Further engagement and development work is planned over the next 6 months and beyond. Similarly, development work has continued with the 6 clusters in South Gloucestershire with this initially 8

12 focusing on cluster 6 as a pilot area in order to test the approach and to help focus resources on supporting the cluster to develop its own leadership structures. The pilot has now also been rolled out to include cluster 5, and work is continuing to focus on supporting the alignment of partners in each cluster and designing ways of working together effectively. This has been supported by the development of performance reporting on the BCF metrics at a cluster level to help inform discussions and drive change. Since the appointment of the project manager (by Sirona) in March 2015 the project has been moving at a pace towards further development of the cluster model in South Gloucestershire. Dependencies with all major project and programmes in the areas are now effectively managed with the cluster project acting as a platform for Connecting Care, Personal Health Budgets, Personalised Assessment Plans, Wellaware development and Dementia work ensuring the services are flexible with working in future cluster system. Connecting Care IT Programme to facilitate care coordination across health and social care Two clusters are now active with all GPs in each area dedicated to designing a local model of integrated working. Engagement with further clusters continues. The Connecting Care programme is a portal that will deliver a shared care record for securely sharing important patient data and information. The IT system is used by GPs, community providers, local authorities, out-of-hours providers, mental health services and local hospitals, and the programme involves collaboration with 17 health & social care organisations. The Connecting Care Partnership has recently been named as the overall winner of the EHI Awards 2015, and has been short listed for the Enhancing Care by Sharing Data and Information category at the 2015 Health Service Journal (HSJ) Awards. Work is now underway on the next phase which will extend the breadth and depth of Connecting Care so that it is a true enabler of connected care across our local health and social care community. This will include: - Increasing the number of people using Connecting Care to 4,000 in 2015/16 - Supporting changes to IT systems and the interfaces into Connecting Care (e.g. Paris to Liquid Logic, RiO to EMIS, Cerner to Lorenzo) - Adding information from South Gloucestershire adult social care system - Adding Children s social care systems from BNSSG into Connecting Care working to support safeguarding and joined up care for children - Introducing the ability to share documents from inside the portal - with initial focus on edischarge Prevention CCG committed to population More information can be found at: The underlying principle within the prevention and self-care plan is that prevention is everyone s business and 9

13 level health improvement is relevant across the pathway. Reflecting on local analysis and national guidance, prevention and self-care principles have been identified and agreed for South Gloucestershire. The CCG and South Gloucestershire Council have agreed a joint Prevention and Self Care Plan, and work is underway on developing a supporting work programme.. Cross-cutting Priority 11: Continue to focus on PPI across the CCG s work programmes, in line with PPI strategy principles for good involvement There are good examples of work in progress and several prevention initiatives have been identified for 2015/16. These initiatives are pre-diabetes, alcohol harm reduction, exercise for lower back pain, multimorbidities and mental health and wellbeing. Public involvement in shaping services and making difficult choices To date, 2015 has seen Patient and Public involvement continue to play an integral and important role in the meeting of the CCG objectives in the work programmes. The PPI team has developed a work plan with commissioners focused on the QIPP plan and our Commissioning Priorities to ensure patient and public involvement is integral to all the service change developments taking place across the organisation. Members of the PPI team work on project steering with commissioners, clinicians and the communications team to produce Patient and Public Involvement Plans for each service change project. A new template for PPI plans has been agreed which has helped to ensure consistency of process across the CCG. We have produced PPI plans appropriate to the needs of each service change using a number of approaches over the last six months. For example, the Children's Community Health Services re-procurement consultation launched on 3 September 2015 is an innovative online consultation, developed together with colleagues across the BNSSG area, and produced with young people themselves. The use of a largely online consultation has been driven by the wishes of the young people themselves, and is suited to their needs, but we recognise this is not always appropriate and we are flexible in our approach to PPI. A further example is the recent consultation on Patient Transport Services which recognised many of the existing service users may not have access to the internet to complete an online survey, and it would be more effective to talk to them face to face. Therefore the existing service provider approached the service users at the time of their journey. A range of PPI activities have been taking place over the last six months including surveys, attendance at voluntary sector networks and meetings, events such as service design workshops where service users and carers are invited to participate, and involvement of lay representatives within our procurement processes. 10

14 Cross-cutting Priority 12: Patient-centred care, with services designed around the patient. Improvements to be taken forward as part of the implementation of urgent and emergency care strategy, and the Better Care Fund programme The improving patient experience forum (IPEF) continues to strengthen the voice of service users, and held an Away Day in May. New ways of working as a group were agreed, making the forum more effective in its role in assuring PPI obligations are met. IPEF is an important forum used regularly for input into the design and approach to CCG service change, as well as providing a conduit for information sharing with the groups represented at IPEF, such as the Race Equality Network and Disability Equality Network. Where the CCG has consulted with members of the public and patients, plans have been put in place to ensure these views are not only captured, but reflected within our service design. For example, an assurance exercise was carried out for the Children's Community Health Services re-procurement work which ensured the messages we had heard during the pre-procurement phase had been reflected within draft service specifications. Changing the culture guiding principles for improving patient experience The South Gloucestershire Better Care Fund plan, of which the 3Rs and Cluster integration projects are key constituent parts, is all about person centred and individual care and support, to enable individuals to remain well and at home for as long as possible. Over the past 6 months, the focus of work in these areas has been to develop the infrastructure to enable this personalised support to be provided. The development and testing of the 3Rs model has had a key focus on the provision of a range of services, including community rehabilitation beds (and associated support) in care homes, and home support in order to provide flexible services which can effectively meet the needs of the individual and ensure that they can receive appropriate care and support outside of an acute hospital setting. Feedback from patients and carers has so far been overwhelmingly positive and the lessons learnt and feedback on existing services has played a key role in the development of Phase 2 of the programme. Similarly, the development of the cluster integration model has involved patients, carers and service users in their design and development to ensure that the focus remains on the individual. This has included work looking at developing a voluntary and community sector link worker model and effective signposting to ensure that individuals are able to readily access the support and care which best meets their needs. The CCG has piloted more integrated working in four practices this year, funding Age UK to work with people with more than one long term condition to identify and achieve their personal goals. Initial indications are very positive, with the participants reporting that their wellbeing has improved by 25%. The CCG will receive the 11

15 formal evaluation of the project later this year and decide what to do in the future. 12