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Southwark 5 Year Forward View SummarySOUTHWARKFive Year Forward Viewof health and social care2016/17 to 2020/21

Southwark Five Year Forward View SummarySouthwark Five Year Forward View SummaryWELCOMESouthwark is a vibrant place to liveto our Southwark Five Year Forward ViewWe want the best possible health and social care outcomes for Southwark people. Weset this out in our Southwark Five Year Forward View. It describes Southwark Counciland NHS Southwark Clinical Commissioning Group’s (CCG) shared vision for localservices. This summary aims to encourage discussion with Southwark people on how toachieve our vision.The way we do things now doesn’t always result in the best outcomes and experiencesfor local people. Pressure is increasing on health and social care services, and we needto think differently so that people havethe best care when they need it.This is about improving quality and overallvalue. If funding wasn’t anissue, we would still want to radicallyimprove outcomes. We know thatwe can improve things if we worktogether in a new way.“We want Southwark citizens tofeel in control of their lives andtheir care, with the servicesyou use planned with you,around your individual needs.”Southwark is a diverse, vibrant and growing borough of almost 300,000 people.In comparison to other places in England, Southwark is relatively younger,more densely populated and more deprived. In the 2011 census 18,978 peoplereported that they had a long term health problem or disability.Recent improvements include reductions in infant mortality; better care forpeople at the end of their life; better outcomes for people with HIV, and a risein life expectancy. But there are real challenges and too many people live withpreventable ill health, or die early.Did you know?There is a difference inhealthy life expectancybetween the richest andpoorest in our populationof 7.6 years for males and6.7 years for females.Local services often respond well to a crisis,but we have to find ways of reducing thenumber of people who need crisis supportin the first place. We can’t just wait forpeople to get ill or need urgent social care,and deal with the consequences. We knowwe need to promote health and wellbeing,and invest our resources into preventionand early intervention.All of our future plans willbuild upon the principles setout in the Southwark Five YearForward View. We look forwardto discussing our plans with youand will publish an action plan‘Southwark Forward View: IntoAction’, in summer 2016.Dr Jonty Heaversedge,Councillor Stephanie Cryan,Chair NHS Southwark CCG Cabinet Lead for AdultCare and Financial Inclusion23

Southwark Five Year Forward View SummarySouthwark Five Year Forward View SummaryLocal people also want better, more coordinated careWe have worked closely with local people who use health and social care services tounderstand what they would like to be able to say about their care. These “I” statementsare the outcomes that people say are important if and when they need care.We have a common purposeto improve local servicesI want to have systems inplace to help at an earlystage to avoid crisis, and assmall a disruption as possibleif a crisis happens.Southwark Council and NHS SouthwarkCCG want to see:nn an increase in healthy lifeexpectancy, adding life to yearsas well as years to lifeI want to be able to livethe life I want and get thesupport I need to do that.nn a reduction in health inequalitiesacross communities in Southwarknn more people engaged in their ownhealthcare, so that individuals andfamilies are directly involved inmaintaining and improving theirown health and wellbeing4nn a greater proportion of peoplereporting better experiences when theyuse health and social care services.The large financial challenge acrosshealth and social care makes theimprovements not only desirable butnecessary. As our population, and itshealth and care needs grow, we needto manage within existing resources.We want to nurture resourcefuland flourishing communities,supported by health andsocial care services that aregenuinely person-centred andcoordinated. This is not thesystem that we have currently.We don’t believe that ‘more ofthe same’ is the best option.People should be supportedand treated in the right placeat the right time according toneed, with much more careprovided closer to home.I want to feel safe, secureand protected from harm.I want to be able to managemy own health and wellbeingor condition and besupported to do this includinghaving access to informationand being able to stay healthy.I want to be able to plan my carewith people who work togetherto understand me, allow mecontrol, and bring togetherservices to achieve the outcomesthat are important to me.5

Southwark Five Year Forward View SummarySouthwark Five Year Forward View SummaryDay-to-day experiences of care highlightthat things could work betterLocal services are staffed by skilled andcommitted people. Despite this peoplecan feel confused and frustrated. Arecent Special Inquiry by Healthwatchfound that:nn people can experience delays anda lack of coordination betweendifferent servicesnn people can feel stigmatised andthat they are not treated withappropriate respectnn people don’t always feel involvedor informed in decisions abouttheir carenn people can feel that their full rangeof needs is not being considered.nn people can feel left without theservices and support they need afterdischarge from hospitalThe voices of Southwark people: statements from SouthwarkHealth and Wellbeing Board’s 1000 lives research“I am a pensioner with ulceratedlegs. I need compression andsteroid cream once a week.Booking GP appointments isnot good. 10 minutes is notenough for a consultation. GPsare stressed and they’re doingtoo much. And there aren’tenough district nurses. And theyneed to share information. I’mconstantly telling my story overand over again”6Making improvements will depend on us addressingsome complex issuesWe need to address a number ofcomplex and interwoven issues tochange the current system. There is no‘one size fits all’ solution, but we knowwe need to tackle three fundamentalproblems with the current system:nn The disempowerment of patients,service users and carers createsconfusion, and risks making peoplepassive recipients of care, ratherthan being actively involved in theirhealth and wellbeing.nn The fragmented arrangement oforganisations and professionsreinforces boundaries whichcan make it too difficult to worktogether consistently.We know we need to learn from localexperience, and take a supportiveapproach to transformation. We willfocus on building relationships, changingculture and developing our communities,building a strong local partnership tooversee and govern the transformationprocess over the next five years.nn Fragmented contractingarrangements make it difficult tomove resources to where they areneeded to deliver what reallymatters to people.“My son when he was twowas diagnosed with cognitivecommunication difficulties. Weare at the stage of waiting forthe school speech and languagetherapist to pick it up. He isfour now. Health services arequite good. Although there isa gap between Early Yearsand school picking it up.The school has made thebiggest difference”7

Southwark Five Year Forward View SummaryFragmentation means that services don’t take aholistic view of a person’s needsMichael’s story is an illustrativeaccount, showing how a holistic,whole person approach whichconsiders health, social andeconomic needs could make areal difference.Michael is 62. He moved to Southwarkten years ago for work, but hasrecently been made redundant. Helives alone in rented accommodation.Since losing his job Michael sees fewerpeople. He worries about his rent,and growing debt.Michael has insulin-dependentdiabetes and depression. He knows heshould eat better and exercise more,but it feels hard; going to a gym isanother expense and it’s quick andeasy to eat take-away food.Michael feels things are outof control, and his onlyreal comfort is alcohol.8The police have taken Michael to A&Efour times in the past six months,after he collapsed in the streetfollowing particularly heavy drinking.His diabetes is a problem; he hascalled an ambulance twice in the pastmonth and been admitted intohospital with hypoglycaemia becausehe hadn’t eaten enough.In hospital Michael met other peoplewith diabetes. One person had had aheart attack related to diabetes. Shehad also had an amputation last yearas her leg ulcers refused to heal. Shetold Michael that she wished someonehad helped her before it was too late.When Michael was discharged he wasvery worried; he didn’t want to have aheart attack or end up needingan amputation but he didn’tknow what to do.In future care will be more integratedand coordinated because:nn GPs, nurses, social workers andhospital consultants will collect anduse information to identify peoplelike Michael early and arrange thebest support for them. Integratedteams will understand all of hisneeds and capabilities.nn Michael will be able to meet otherpeople who are experiencing similarthings in peer-support groups. Hewill be able to access education andself-management support to feelmore confident and live well with hisconditions. Michael will feel reassuredthat he can contact a care teammember quickly, if he needs to.nn The team will have the time tounderstand Michael, what isimportant to him and his goals.Michael’s mental and emotionalneeds will be considered equal tohis physical health needs, and hiscare team will include psychologistsand psychiatrists.nn Michael will find it easier to accesssocial activities and groups, and feelmore connected and able to makefriends. He will get practical advice onissues like housing, debt-management,benefits, and employment.nn The team will use techniques likeproactive care planning to helpMichael start to take control ofhis life. Michael will feel like he isworking with an expert care team,rather than just being treated bythem or being told what to do.nn Living a healthier life will be simpler.Michael will know where the localparks are, and that they’re safe. Hewill be able to access free gyms andswims, and cycling and walking willbe easier because the roads will besafe and well lit.9

Southwark Five Year Forward View SummaryTo make this happen theCCG and Council will beginto work differentlyOver the next five years we willintroduce better ways of workingacross health and social care,working together to:What will it meanfor local people?“I feel in control of my lifeand the care I receive, andI know what’s going on”nn plan and fund care that respondsto the needs of local populations,rather than based on what hospitalservices, community care andgeneral practice have always done“Professionals worktogether to support me”nn fund care with an increasing focuson whether the services actuallymade a difference to the outcomesthat local people say are importantto them“The little but importantthings are thought about”nn encourage closer working betweenhealth and social care providersnn support and develop our twoLocal Care Networksnn support our vibrant and diversevoluntary and communityorganisations to work moreclosely with health and social care.10Southwark Five Year Forward View SummaryOur approach to commissioning will changeThree main principles will help us to achieve our shared purpose:1 We will contract on the basis of populations rather than providers.nn Inclusive contracts for defined segments of the population will coverthe physical and mental health, and social care needs of people withinthat group.nn Populations can be geographic or based on common characteristics, forexample children and young people, people with severe mental illness,or multiple long term conditions.nn Contracts will focus on outcomes including safety, effectiveness andexperience of care services.nn Contracts will be available to providers who can bring together the skillsrequired to meet population needs.2 We will focus on whole system value rather than individual contract prices.What is a LocalCare Network?A range of health careprofessionals working togetheras a team in the communityincluding doctors, nurses, socialworkers, housing supportworkers, home care workersand therapists who work with apatient to achieve the goals thatare important to them in a clearjointly agreed way.nn Resourcing services that create better outcomes, focusing on theoutcomes achieved as well as the quantity of activity delivered.3 We will emphasise that ‘how’ care is delivered is as important as‘what’ care is delivered.nn Services consider people’s mental and physical health and socialcare needs equally, and are sensitive to social, environmental andcultural needs.nn Services manage problems proactively and don’t just wait for people toget ill, and reach crisis point.nn Organisations and professionals integrate, coordinating care witheach other.11

Southwark Five Year Forward View SummaryWe are confident that we can work together totransform health and social care in SouthwarkSouthwark Council and NHS Southwark CCG have been working on this agenda forseveral years with partners across Southwark, Lambeth and south east London. There arealready examples that demonstrate the potential for new ways of working together.nn CCG and council budgets broughttogether in our Better Care Fund,and invested in avoiding hospitaladmissions, better supporteddischarge from hospitals, and morecoordinated and proactive care.nn Collaboration between generalpractices in north and southSouthwark, with these GP federationsforming the foundation for new LocalCare Networks. GPs can improveservices by working together, andalready offer extended access, 7 daysa week, 8am-8pm.nn Innovative diabetes model whichaddresses medical, psychological, andsocial needs. 98% of our GP practicessigned up, resulting in improveddetection and control of diabetes.nn Better information sharing with aLocal Care Record allowing hospitalsand GP teams to see each other'spatient records instantly.nn Active and energetic network ofresidents involved in transforminghealth and social care. EachSouthwark general practice has aPatient Participation Group (PPG); theSouthwark and Lambeth Citizens’Forum and Citizens’ Board bringpeople together to influence andactively participate in new initiatives,making sure that service changes meetthe needs of the people who use them.Get involvedTell us what you think. There are many ways to shape our plans, and toget involved in local initiatives. To find out more:nn See www.southwarkccg.nhs.uk www.southwark.gov.uknn Email souccg.southwark-ccg@nhs.netnn Call 020 7525 7888To read the Southwark Five Year Forward View in full,see www.southwarkccg.nhs.uk12

set this out in our Southwark Five Year Forward View. It describes Southwark Council and NHS Southwark Clinical Commissioning Group’s (CCG) shared vision for local services. This summary aims to encourage discussion with Southwark people on how to achieve our vision.

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