Better Health and Sustainable Healthcare for Bristol

Bristol Clinical Commissioning Group

Dr Martin Jones

Chair Bristol CCG

The challenges• Deprivation, lifestyle issues (alcohol, obesity, exercise) and

significant inequality of outcomes– Population in Bristol generally worse outcomes than

population overall : (cancer, heart disease), with significant inequalities within that

– Difference in the number of children living in poverty is almost 10 fold between areas and rising younger population amongst deprived

• Significant financial challenge across all partners• Significant performance, capacity and system resilience issues• System complexity: multiple providers, councils,

commissioners, universities and small area variation in population

The opportunity in Bristol• Vibrant non statutory sector: supports 5YRFV view -

NHS as a “social movement”• Academic involvement and clinical expertise• Primary care co-commissioning and record of

innovation • Powers of mayor in leading HWB action• At scale prevention model started • Integration and personalisation agenda started• Developing a shared vision of health and care for the

population: developing joint working with council

Bristol CCG prioritiesImproved outcomes and clinical pathways

Integrated working across health, social care and voluntary sectors (doing things differently)

• Earlier cancer diagnosis• Improved vascular outcomes (vascular

disease is caused by inflammation and weakness of the veins and arteries)

• Joint work with partners on taking forward the alcohol strategy and other key preventative strategies and services

• Understand and address inequalities in health

• Modernising mental health services• Managing growing demand for

children’s services

• Integration of services and care coordination

• Self-care and prevention, working with individuals, communities and providers

• Long term conditions: providing care closer to home

• Developing new ways of working and models of working, including working with primary care

• Personalisation of care

Our key areas of work:Clinical steering group Programme

• Improving outcomes, reducing variation and managing demand through clinical redesign. cancer, MSK, diabetes, CVD, respiratory

• Improving mental health services including IAPT recommissioning, and services for those with dementia

• Cost effective medicines management• Managing demand for children’s services (recommissioning)

Transformation Programme: Bristol Model of Care and Support (Out of Hospital)

“Better Care Bristol” Joint work with council to deliver: • Prevention, self care hub (s), social prescribing • Integrated community teams (recommissioning)• Support for multi morbidity/frailty and complex conditions• New models of urgent care e.g. “front door”, SPA, care home support• Rehabilitation and reablement

Joint working with NHSE to deliver:• new models of primary care

Enabling Programmes

IT to support system and care coordination (Connecting Care) , workforce, estates

System flow and capacity and demand planning

Delivery to NHS Constitutional StandardsUrgent care capacity and flowSystem coordination

Bristol Clinical Commissioning Group Delivery Plan: Better Health and Sustainable Healthcare for Bristol

1

Acute and

mental health beds

Primary care practices working together in new ways with each other, with GP, community and acute specialists and

integrated community teams

Neighbourhood support, social prescribing /health and wellbeing services working with the voluntary sector and with communities

Clinical steering groups Redesign for improved outcomes, clear pathways of care and standards of delivery: Urgent care Planned care Frailty pathway Long Term

Conditions (including diabetes, circulatory disease)

End of life care Mental health Dementia Cancer Children’s Maternity Learning disability

Self-care support, prevention, addressing health inequalities working with public health communities and with individuals

Acute and mental health “front door” assessment,

treatment and non-bed based services

System coordination and access for professionals (SPA, referrals

management) and public (NHS 111, 999,

Enabling: IT Workforce Estates

NHS Outcomes Framework Domain 1: Preventing people from dying prematurely Domain 2: Enhancing quality of life for people with long term conditions Domain 3: Helping people to recover from episodes of ill health or following injury Domain 4: Ensuring that people have a positive experience of care Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm

Keeping people well, preventing admission and supporting close to home where possible

Enabling prompt and safe return to home or near to home as possible

Better Care Bristol: Model of care and supportHealth and social care integration to support individuals and communities with coordinated

care and urgent responses in the community for their physical and mental health needs

An example: diabetes• Available, targeted approaches to reducing obesity, working

with council and communities (e.g. health champions) supported by self care/lifestyle hub, information and advice that is consistent and system wide

• Referral “social prescribing” options for GPs that include healthy eating classes (run by local groups and tailored to their needs); exercise and weight loss classes etc

• High quality, consistent primary care, integrated with community and specialist teams to support individual to manage condition safely at home, using personalised care plans, monitoring, technology and patient education

• Clear pathways when specialist support is needed outreaching from the hospital, working with primary care

• Prompt, supported, coordinated discharge from hospital back to primary care