sara radcliffe: integration in central manchester at scale and pace
DESCRIPTION
Sara Radcliffe shares how community staff from across health and social care in Central Manchester have been working together to improve outcomes for patients by transforming intermediate care. Central Manchester’s Clinical Integrated Care Board (CICB) is a partnership of Central Manchester Clinical Commissioning Group, Central Manchester Foundation Trust, Manchester City Council, Manchester Mental Health and Social Care Trust and the North West Ambulance Service.TRANSCRIPT
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Central ManchesterHealth and social care system
NHS Central Manchester Clinical Commissioning Group
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
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In Central we believe in joined up care
In Centralwe will design services to a
shared care model
In Central we will
communicate, inform and
educate
In Central we will redesign our health and
social care system
Central ManchesterHealth and social care system
Leaders with a joined up
vision
NHS Central Manchester Clinical Commissioning Group
Clinical integrated care
board
Urgent care board
Planned care board
Transforming community
services board
Transactional redesign board
Integrated care teams taskforce
MembersExecutive 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
Central ManchesterHealth and social care system
Leaders prepared to put the time and talent in
NHS Central Manchester Clinical Commissioning Group
EOLDistrict nurses
Care home staff Patients and families
Active case managersSocial care
GPs OOH Falls
AmbulanceIntermediate care
Community alarm team Patients and families
District nursesFalls services
Social careGPsOOH
COPDCOPD team
Active case managersPatients and families
Intermediate careSocial careMcMillan
GPsOOH Practice
integrated care teams
21 practicesSocial care
Community nursesMedicine management
Specialist teams
Central ManchesterHealth and social care system
Just start it and see where it takes us
NHS Central Manchester Clinical Commissioning Group
Can we reduce admissions,
lengths of stay and
readmissions ?
An integrated care programme for Manchester
“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”
People, pride, placeLiving longer, living better
The goal Prepare to change the path to get to the right
place
NHS Central Manchester Clinical Commissioning Group
Our people /population pyramid
Our service model for out of hospital
care
Our system
Our workforce
Our money
Our buildings
Our Information
Social movement
People, pride, placeLiving longer, living better
1 council
4 trusts
3 CCGs
500,00+people
Its massive, its complex ,
lets make sure its worth it
NHS Central Manchester Clinical Commissioning Group
Low ModerateHighVery High
342,253
36,88194,193
13,708
5,805 4,3983,346
6,114
19,531
3,0531,6661,8451,5141,2621,270
691
753
563
452
328
Increasing risk of admission
80%
20%
Our people
People not patients
with lives not
conditions
CO-ORDINATION OF SHARED CARE
Our care model
Low
70,17
668
%
Moderate22,704
22%High7224 7%
Very
High
3096
3%
OUTCOMESOFFER
NHS Central Manchester Clinical Commissioning Group
What's the offer, what will
be the outcome, how will we do it ?
Our moneyInvestment
ImplementationImpact
Return on investment
Virtuous circle – continuous process of resource shift
Commissioning for an integrated system
Best laid plans… New rules, new games or new system, better outcomes?
Shifting assets - aligning supply and demand in and out of hospital
Alliance + ?
Need to make the money
work – can we have shared and owned
risk and gain ?
NHS Central Manchester Clinical Commissioning Group
Executive Health and Wellbeing Group
System GovernanceNorth Manchester
System GovernanceCentral Manchester
Integrated Care Board
System GovernanceSouth Manchester
Citywide leadership group
Programme Office
Reference group
Health and Wellbeing Board
People, pride, placeLiving longer, living better
Leaders with vision....
Back to the beginning
but bigger - if it’s to be sustainable
NHS Central Manchester Clinical Commissioning Group