Integration in central Manchester at scale and pace May 2013

Central Manchester
Health and Social Care System
Integration In Central Manchester
At Scale and Pace
Sara Radcliffe Central Manchester University Hospitals NHS
Foundation Trust
Emma Gilbey Manchester City Council
Dr. Ivan Benett Central Manchester Clinical Commissioning Group
Ed Dyson Central Manchester Clinical Commissioning Group
1
Central Manchester
Health and Social Care System
In Central
we will design
services to a
shared care model
In Central
we will
communicate,
inform and
educate
In Central
we believe in
joined up care
Leaders with
a joined up
vision
In Central
we will redesign
our health and
social care
system
2
Central Manchester
Health and Social Care System
Leaders
prepared to
put the time
and talent in
Clinical
Integrated
Care Board
Urgent care
Board
Planned Care
Board
Transforming
community
services Board
Members
Executive level clinical and managerial leadership from:•Central Manchester CCG
•Central Manchester Foundation Trust
•Manchester City Council
•Manchester Mental Health and Social Care Trust
•North West Ambulance Service
Transactional
Redesign
Board
Integrated
Care Teams
Taskforce
Central Manchester
Health and Social Care System
COPD
Just start it
COPD team
and see
Active Case Managers
where it
Patients and families
takes us
Intermediate Care
Social Care
McMillan
GPs
Falls
OOH
Practice
Ambulance
Integrated Care
Intermediate Care
Teams
Community Alarm Team
21 practices
Patients and families
Social Care
District Nurses
Community nurses
Falls services
Medicine management
Social Care
Specialist teams
GPs
OOH
EOL
District Nurses
Care Home Staff
Patients and families
Active Case Managers
Social Care
GPs
OOH
Can we reduce
admissions,
lengths of stay
and
readmissions ?
People, Pride, Place
Living Longer, Living Better
The Goal
“My care is planned with
people who work together to
understand me and my carers
put me in control, co ordinate
and deliver services to achieve
my best outcomes”
Prepare to
change the
path to get
to the right
place
An Integrated Care Programme
For Manchester
People, Pride, Place
Living Longer, Living Better
Our People
/population pyramid
Our Service Model
for out of hospital
care
Our Money
Its massive,
its complex ,
lets make
sure its
worth it
Our buildings
1 Council
4 Trusts
Our System
Our Workforce
Our Information
Social Movement
3 CCGs
500,00+
people
Our People
328
452
563
753
691
1,270
Increasing risk
of admission
1,262
1,514
1,845
1,666
3,053
3,346
4,398
5,805
6,114
13,708
19,531
36,881
94,193
342,253
Low
Moderate
High
Very High
People not
patients
with lives
not
conditions
20%
80%
Our Care Model
What's the
offer, what will
be the
outcome, how
will we do it ?
Moderate
22,704
22%
OFFER
OUTCOMES
CO-ORDINATION OF SHARED CARE
Our Money
Return on
investment
Impact
Investment
Implementation
Virtuous circle – continuous
process of resource shift
Commissioning for an
integrated system
Alliance
+?
Shifting assets - aligning supply and
demand in and out of hospital
Best laid plans… New rules, new games
or new system, better outcomes?
Need to make
the money
work – can we
have shared
and owned
risk and gain ?
People, Pride, Place
Living Longer, Living Better
Health and Wellbeing Board
Executive Health and
Wellbeing Group
Citywide leadership group
Reference group
Programme Office
System Governance
North Manchester
System Governance
Central Manchester
Integrated Care Board
Leaders with
Vision....
Back to the
beginning
but bigger if its to be
sustainable
System Governance
South Manchester