The document discusses plans to transform primary care in Berkshire West CCGs to meet the challenges outlined in the NHS Five Year Forward View. Key points include: developing new models of coordinated care across primary, community, and social care; transforming primary care through increased access and a focus on admissions avoidance; and greater emphasis on public health and improving mental health services. The refresh will focus on hospital services, urgent care systems, and integrated out-of-hospital care.

1. Berkshire West CCGs
Operating Plan Refresh
2015/16
Working together to
keep people well and out of hospital

2. 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
• Patients more in control of their own care
• Better use of innovative technology

3. Changes needed
• New model of care provision which meets financial
constraints
• Coordinated “wrap around” care enabled by different
resourcing for primary, community and social care
• Hospital care delivered in the community
– building on the success of our diabetes work in Berkshire West;
professionals working together beyond hospital walls
• Focus on health and wellbeing, collaborating with
Public Health to support patient self care

4. Our
focus
areas
Hospital
services
Urgent care
system
Out of
hospital sector
Integrated primary, community
and social care at scale

5. The right care in the right place
• Physical and mental health needs of equal status
• Improving access to Mental Health services
- particularly Tier 3 Child and Adolescent Mental Health
• Piloting new technology-enabled care
• Innovative approaches to transform clinical pathways
• Highly responsive urgent and crisis care services
outside of hospital
• Helping people to know where to go and providing better
information to support individuals to self care
• Meeting waiting time targets for A&E, cancer and
outpatients

6. Out of Hospital Services
• Better Care Fund to deliver more services provided
in the community, developed in partnership with
social care [example - Hospital at Home and Neighbourhood clusters]
• Primary care investment to place GPs at the centre
of coordinating care for people with long term
conditions
• A single point of access to health and social
services for patients, carers and professionals
• Responsive, integrated health and social care
services to get hospital patients home sooner

7. A Call To Action
The vision of your local CCG
Dr Abid Irfan – CCG Chair

8. Our local Health Challenge
• Age Profile: we have a larger proportion of older children aged 10 to 19 and adults aged
40 to 49; and a smaller proportion of younger adults aged 20 to 34
• Ageing population an anticipated growth in the over 65 population of 34% (or 8,000
people) by 2021
• Pockets of relative deprivation The most deprived areas are in parts of Greenham,
Thatcham North and Victoria. Greenham is in the 20% most deprived nationally.
• Obesity Overall is lower than national average but approximately 30% of year 6 children
are overweight or obese.
• Smoking prevalence lower than the national average.
• Disease prevalence: cardiovascular diseases, COPD, diabetes, chronic kidney disease,
mental health disorders, depression and dementia are lower than the national
prevalence rates and comparator CCG group. The prevalence of asthma is higher.

9. • New models of care and joint commissioning
e.g. Diabetes, chronic respiratory disease and Hospital at Home.
• Transforming primary care
e.g. Increased Access (Winter pressures & Saturday Opening) and focus on
Admissions avoidance through Community Enhanced Services
• Greater emphasis on improving public health
e.g. Pre Diabetes and Health Checks
• Parity of Esteem for Mental Health Services
e.g. Hospital Psychiatric liaison service and Crisis Concordat. Support for
carers. Focus on Dementia
• Better use of innovative technology
e.g. Connected Care project (MIG & Orion), DXS, E-prescribing, tele
consultations
Delivering in line with the NHS 5 year forward view

10. Operating Plan refresh 2015/16 -Local objectives
• Draft ‘Plan on a Page’ within welcome pack showing refreshed commitments,
alongside examples of areas we have focussed on following previous Call to Action
events. Feedback welcome
• Promote healthy lifestyles in partnership with Public Health
• To develop a sustainable model of Primary Care locally.
• Continue to Increase the timely diagnosis of dementia rate
• Work in partnership across Berkshire to improve outcomes for people experiencing
mental health crisis through the crisis concordat, street triage and increasing self-
referrals to talking therapies.
• Create joint system-wide integrated pathways across key areas such as frail elderly.
Develop new models of delivery of care.
• Continue to deliver our constitutional commitments such as bringing health and
social care system together to ensure consistent delivery of the 4 hour A&E target,
18 week waits and Cancer
• Ongoing development of services at West Berkshire Community Hospital

11. Importance of integration with
Social care
Introduction to Tandra Forster
Head of Adult Social Care West Berkshire Council

12. Importance of integration
with Social care
Tandra Forster
Head of Adult Social Care

13. The headlines

14. Challenges
 Austerity
 Health funding gap from rising demand is set to be £30bn by 2021
(Nuffield/NHS)
 Local Government Association project gap in local government funding of
£16.5bn by 2020
 Ageing population
 By 2030 the number of older people with care needs is predicted to rise by 61%
 Ageing workforce – recruitment challenges
 Burden of disease
 People with Long term conditions account for 70% of health and care spending
 As of 2011, 52% of over 65s had a limiting long-term health condition or disability
– a 50% increase since 2001.

15. Key drivers of change

16. Care Act 2014 – more challenge
 Embeds personalisation
 Opens up key role of carers
 Wellbeing
 Prevention
 Good quality information and advice
 Robust care market – quality and choice
 Caps the cost of care to the individual (April 16)

17. ‘Whole Place’ approach to Health and Social
Care Integration
 Health and Social Care is a complex network with many
different essential services
 Better Care Fund - government initiative to kick start
integration
 We need to focus on:
 Developing a shared understanding of local need
 Plan together
 Integrate services

18. Making change happen
 Service improvement by improving:
 Communication
 Coordination
 Teamwork
 Simplification
 Aligned budgets

19. Shift our focus
 Focus on strengths not deficits
 ‘Doing with, not to’
 Part of the solution
 Creating resilient communities

20. Vision for 2019
 Person centred services that focus on outcomes rather than outputs
 Provision of good quality information and advice that empowers people to make
good choices and self-manage
 Flexible services that operate across 7 days where appropriate.
 Services will be simpler to access, have less duplication and reach service
users/patients earlier.
 Delivery of health and social services to be localised wherever possible including
access to crisis,
 A greater range of local services that promote independent living
 Reduction in avoidable hospital admissions.
 Lengths of stay in Hospitals will be kept to a minimum
 Increased numbers taking up of personal budgets

21. Angus Tallini
GP Lead for Primary Care NDCCG
5th March 2015

22.  Monday Morning…
 Rising Demand from multiple sources,
including GPs themselves
 Demographic changes
 Workforce changes
 Organisational factors

23. Hospital
care
Urgent
care
system
Out of hospital
sector:
Integrated
primary,
Community
and social care
at scale

24. Alleviating
current pressures
Effective co-
commissioning of
primary care
services
Incentivising
innovation

25. A Rewarding
Place to Work
– with a
training focus
Offering timely
appointments over
extended week in
accordance with
patient need
Integral part
of urgent care
system
Continuity where it
matters most to give
proactive and
coordinated care for
‘at-risk’ patients
Preventative
Supporting
patients and their
carers to self
manage
Long Term
Condition
Fit-for-
purpose
premises
Sustainable
and good
value
Signposting to
facilitate
appropriate usage
of GP and wider
services by
patients
Continuing to
provide high
quality care
Using
Technology to
optimum
effect
Offering defined
level of care
through varying
delivery models

26.  Comprehensive Directory of Services
and active signposting at the front door
 Supported self care
extending to long term conditions
 Continuity when it matters most
with a team supporting each GP within the practice
 Urgent primary care capacity
co-operative approach to on the day demand