The Sutton Health and Care Plan

THE SUTTON HEALTH AND CARE PLAN

Discussion Document

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Contents

1. Introduction ...... 3

2. Our Health and Care partnership and joint vision ...... 4

3. Our health and care challenges ...... 5 Our challenges ...... 5 Start Well ...... 5 Live Well ...... 7 Age Well ...... 8 Feedback from residents of Sutton...... 9

4. Our case for change ...... 11

5. Our Sutton Health and Care Plan ...... 12 Our strategic approach ...... 13 Our priorities, initiatives and benefits...... 18 Start well ...... 18 Live well ...... 21 Age well ...... 23

6. The financial context of our plan...... 28

7. Our roadmap for delivering the Sutton Health and Care Plan ...... 31

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1. Introduction

The Sutton Plan sets the strategic direction  sets out our joint approach and some of and ambitions of Sutton Council (the Council) the improvements we will be working to and Sutton Clinical Commissioning Group achieve over the next five years. (CCG) to deliver better health and wellbeing  forms a foundation for how we will start outcomes for local residents by working to deliver against the priorities and closely with a wide range of stakeholders, local requirements in the recently published people and carers who use services in Sutton. NHS long-term plan, including how we: o move to a new way of working in Work has been undertaken over the past year Sutton through the establishment of by the Council, CCG, community and voluntary an Integrated Care Place with sector and Healthwatch Sutton, with the partners in Sutton working together assistance of the South West London Alliance, to define and drive the strategy and to look at what is important for health and transformation plans that will ensure care in Sutton over the next five years, what that the right care is delivered in the the challenges are, and how different right place for local residents. organisations can work even more closely o ensure we deliver services with a together to make a sustainable difference for strong focus on self-care, health Sutton residents. promotion and prevention. o tackle the social determinants of Our aspiration is that people of Sutton are health and reduce health supported to start well, live well and age well inequalities. through a more personalised and joined-up o integrate health, care and approach to the delivery of health and care community and voluntary sector services in Sutton. Local leaders have come services, where it is right to do so, to together through the Sutton Local support Sutton to be financially and Transformation Board to develop a Sutton clinically sustainable. Health and Care Plan that:

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2. Our Health and Care partnership and joint vision

In Sutton our local health and care partners  places underpinned by inclusive and are: sustainable growth.  Community Action Sutton  a coherent system of health and care that  Epsom and St Helier University Hospitals is shaped around the needs of Sutton’s NHS Trust residents.  Healthwatch Sutton  London Borough of Sutton Our Sutton Health and Care Plan builds on the  NHS Sutton Clinical Commissioning Group third priority and the commitments that  South West London and St George’s underpin it, which are to: Mental Health NHS Trust  collaborate on a better system of health  South West London Health and Care and social care that provides responsive, Partnership seamless, personalised and affordable  Sutton GP Services Limited services for all of those that need them -  Sutton (London Borough) Public Health reducing the need for expensive in-  The Royal Marsden NHS Foundation Trust hospital care.  further promote single point of access As partners our shared vision for the future of services that are easy to navigate and Sutton as stated in The Sutton Plan is that: offer the right care at the right time.  build upon existing initiatives to increase We want to sustain and develop the good individual and community resilience. quality of life, access to decent jobs and services, and strong communities that we know In delivering our Sutton Health and Care Plan are Sutton’s strengths. We also want to ensure we will continue to aspire to achieving that these benefits are shared by everyone in transformational change by following our five our community, tackling the inequalities partner principles: experienced by some of our residents.  One - think Sutton first  Two - work across sectors We have agreed to work together to deliver  Three - get involved early this vision by promoting 3 key strategic  Four - build stronger, self-sufficient priorities: communities  a better quality of life and opportunity for  Five - provide coordinated, seamless all residents. services

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3. Our health and care challenges

Our challenges There are a number of challenges facing that are affecting the ability of people to start health and care services in Sutton that are well, live well and age well in Sutton are preventing us from delivering better outcomes highlighted below. for our population Some of the key challenges

Start Well

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Sutton is a great place to start and raise a need and the subsequent provision family with a good range of support services of support. and excellent schools. However, we are aware o We need to continue this process so that not every family and child is thriving in that we maximise opportunities for Sutton. We want to raise the bar and tackle children with lower levels of need to this inequality by addressing three main areas be schooled and supported within of concern: mainstream education whenever  School readiness possible (which we know from the o We know that not enough of our evidence leads to better outcomes), children are ready for school by the while at the same time maintaining time they reach their reception year. good levels of specialist provision for This means that too many children those who need it. are not reaching desired levels of o Finally, we know that earlier emotional, social and physical detection of developmental delay development combined with low and needs? can facilitate earlier levels of basic numeracy and literacy. intervention and better long-term o We know this is important as a child outcomes for many conditions. We who hasn’t benefited from the right therefore need to explore how we level of emotional support at home can redesign pathways to improve and in the community is unlikely to rates of early detection and thrive at school and may struggle intervention. with simple tasks such as sitting at a desk, paying attention, socialising  Mental wellbeing for young children with other children or eating or going o Rapid changes in society from to the toilet. increasing childhood poverty and o We have heard the concerns of changes in family structures, to the educational colleagues about rapid rise of social media, or the increasing demand being put on increasing drug use amongst young teaching staff and, worryingly we people, all contribute to increasing know that many of these children fall levels of stress and anxiety amongst behind at both primary school and young people. secondary school; which has a huge o This is creating challenges in impact on their chances in life. addressing an unmet need around mental wellbeing for young children  Children with Special Educational Needs in the borough. and Disability (SEND) o This is an issue that is beyond the o Another inequality that we have to remit or capacity of any one single tackle is the need to maximise agency to address. However, the chances for children with SEND. recent trailblazer mental health Since our last OFSTED inspection school support team aimed at partners have been working hard to providing support for children points improve the fairness and to the ability for partners to transparency around assessment of collaborate together to address this complex issue.

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Live Well

Although there is a wide range of local We also know that far too many of us lead services for people living with a learning sedentary and unhealthy lifestyles and, while disability in Sutton, we know that we need to this has become normal, this means that do more to address inequalities that persist around 65,000 people in Sutton have both in terms of purposeful employment but developed a major long-term condition such also in terms of the health inequalities that as diabetes or high blood pressure. In turn persist e.g. the current national life these conditions have become ‘medicalised’ in expectancy for women and men with a the sense that society feels that these learning disability is still 18 years and 14 years conditions can be simply dealt with through a lower than their respective counterparts in the pill prescribed by the GP. general population.

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However, the evidence suggests that medical therapy is not more effective than making This however also needs to align to a better sustainable changes to our lifestyles. Many of offer to residents to improve their physical these long-term conditions are preventable as and emotional health. We need to consider are their serious long-term complications, public and community assets such as parks both for residents and the health and social and open space and explore how these might care system. Given escalating costs and poor be better used to support self-care initiatives outcomes there is an imperative to do to help residents take control of their lives something different in terms of helping through initiatives such as Park Run, outdoor primary care to improve quality around long- gyms or community gardens. term conditions management and prioritise primary prevention.

Age Well

We know from many examples nationally that In the future, social prescribing link workers building the link between primary care and the could engage residents from the GP practice wider community offer is key to improving not into community interventions to help them just physical wellbeing but also to addressing with their physical, emotional and social emotional wellbeing. Just as we need to have wellbeing, thereby reducing demands on a schemes to prescribe exercise, we also need stretched system but also giving back control to take advantage of national investment to and focus to the individual resident as promote social prescribing which is opposed to leaving it to the hands of the particularly important to tackle social professional. isolation.

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Feedback from residents of Sutton Previous engagement in Sutton also identified across the three areas of Start Well, Live Well some challenges that people felt needed and Age Well is shown below. addressing. Some of the feedback provided

This feedback was reinforced at the Sutton social care, and community and voluntary Health and Care deliberative event held on sectors. A summary overview of the key 29th November 2018, which was attended by messages and feedback received from the about 120 people with representation from event is shown below. residents, and stakeholders across health,

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4. Our case for change

There is a real sense of ambition and desire by  deliver a multi-agency approach that Sutton partners to build on the strength of our improves earlier intervention thereby established partnership. We want to move reducing the need for statutory forward in accelerating our journey of interventions integration to enable us to rise to the dual  improve the quality of advice and support challenges of improving care for residents and offered to families of children with Special maintaining financial balance across the Educational Needs and Disability, and Sutton Health and Care system. people with Learning Disabilities

Many of the challenges that we have Our service delivery model will also have to be highlighted above are beyond the remit of any further enhanced to ensure maximise impact. single organisation to address fully. We This will be driven by the expansion of the therefore believe that system-wide efforts are multi-organisational Sutton Health and Care needed to produce the sustainable Alliance as the joint service delivery vehicle. transformative change needed to improve This will provide a focused approach in care. developing and delivering cost effective integrated services (e.g. planned care, This will be driven by the development of an continuing health care, end of life care) that Integrated Care Place that will provide us with address the identified challenges. a collaborative strategic framework to align our resources to focus on shared local The following sections therefore set out how priorities that for example: we will address these system-wide challenges  improve quality by reducing unwarranted over the next five years. variation wherever it exists

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5. Our Sutton Health and Care Plan A high-level overview of our plan is shown below and highlights the strategic approach, priorities, initiatives and benefits we will be looking to achieve.

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Our strategic approach As Sutton partners we have a commitment borough level for the to establishing an Integrated Care majority of the current Partnership that drives and owns our NHS budgets, to reshape strategic health and care plans. Some of and deliver services at the ways in which we will work to deliver borough level this will be through: o As system leaders across health, social care and the voluntary  Development of an Integrated Care sector in Sutton we have already Place been working together over the o There are a number of past year through the Local organisational changes taking Transformation Board in defining place within the NHS in response and driving local strategy and to the priorities set out in the transformation plans. We are NHS Long Term Plan. This therefore building on our existing includes: governance arrangements and . the 6 South West London joint working successes to CCGs coming together to develop the new Sutton form a single South West Integrated Care Place in 4 stages London CCG (an Integrated so that we: Care System) by April 2020 . deepen our shared with full NHS financial strategic vision and intent accountability for the . further align our joint system strategic planning . development of a new . free up provider partners Sutton Integrated Care to respond as one alliance Place that will have to the Health and Care delegated financial Plan accountability at the local

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o Stage 1 – Establishment of a deliver the Health and Care Plan, Sutton Health and Care Executive by: to develop the Health and Care . producing a 5-Year service Plan, by: development map . reshaping the Local (reviewed annually) that Transformation Board to a sets out how the strategic new Health and Care requirements will be Executive that develops delivered including for the Health and Care Plan, example: and is dually-accountable - priorities for to the Council through the transformation/red Health and Wellbeing esign Board (ensuring delivery - service delivery against the Sutton Plan models vision) and to the new - which services will South West London CCG be delivered by the (ensuring the NHS Long Alliance and/or Term Plan national through contracts priorities are being with other non- delivered) partner providers . ensuring that the Council such as the and CCG plan their community and financial investment in voluntary sector, accordance with the joint schools etc Health and Care Plan, - how these will through an “aligned” support the NHS approach to budgeting financial recovery which preserves the and efficiency necessarily distinct programme governance and o Stage 3 – Service delivery through accountability systems of an Integrated Provider Contract(s) the NHS and Council. where it makes sense to do so, . annual review of the plan by: to ensure key strategic . in the first instance requirements are being procuring integrated met and that the plan services through an continues to be developed appropriate Integrated by commissioners and Provider NHS contract(s) providers together as a that is delivered alongside whole system instead other aligned contracts (instead of the traditional e.g. Council contracts for commissioner/provider social care and/or “split”) education components of o Stage 2 - Sutton Health and Care the integrated services (the Alliance Provider) shaping a service development map to . working together over time as the local system

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matures and national  Expansion of the Sutton Health and legislation changes Care Alliance for provision of children towards potentially and adult community services procuring a single o London Borough of Sutton and integrated NHS and Sutton CCG commissioners have Council contract for commissioned adult community delivery of integrated service, and an integrated services children’s community service on o Stage 4 – Establishment of a an interim basis over the next single peer review assurance two years from the Sutton Health process for the delivery of and Care Provider Alliance that integrated services, by was established in April 2018 and . moving away from current comprised of the following local multiple transactional partners: contract reviews with . Epsom and St Helier individual providers to a University Hospitals NHS more holistic single system Trust approach that uses joint . London Borough of Sutton intelligence, quality . South West London & St improvement Georges Mental Health methodologies and lived NHS Trust experiences to review and . Sutton GP Services Limited improve services o This arrangement provides both commissioners with service  Commitment to aligned continuity, time to implement commissioning between London new models of care with services Borough Sutton and Sutton CCG shaped around people in a more o As local partners we have integrated way, to re-procure developed a Health & Social Care community services that are fit Integration programme that for purpose in the future. brings together what we are o The provision of children and jointly commissioning and/or adult community services by the working to deliver, to ensure we alliance will build on the can deliver better outcomes for provision of the integrated people through a joined-up Sutton Health and Care at Home service planning and service established on 1st April commissioning approach. 2018. o This provides a strong foundation for moving forward together in  Further development of Primary Care shaping and developing the at Scale and Primary Care Networks Integrated Care Place for Sutton, within Sutton through joint strategic o Sutton will continue working with discussions that are focused GP Practices within Sutton and around the Sutton Plan, the Sutton GP Services Limited (our Sutton Health and Care Plan, and GP federation) to further develop the NHS Long Term Plan. joint working between practices at both network and borough

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levels to meet the requirements . understanding of what of the NHS Long Term Plan additional professionals commitments. This will include could further enhance the multidisciplinary teams within provision of care within Primary Care supporting delivery localities. of: o The learning from this first phase . enhanced access to will be used to inform the Primary Care services that development of wider integrated supports the delivery of primary, community and social urgent care in the care multidisciplinary teams community. aligned to the new Primary Care . improved access to digital networks that support people to technologies that enhance maintain their independence. the ability of people and o These expanded teams are likely clinicians to access and to include GPs, community provide care. geriatricians, allied health . proactive personalised professionals like care planning, and physiotherapists, district nurses, anticipatory care provision mental health nurses, and for high need patients reablement teams working typically with several long- together to deliver the NHS Long term conditions. Term plan commitments for . structured medication improved community crisis reviews to support response, reablement and improved medicine proactive personalised care optimisation and safety. provision. . early cancer diagnosis . enhanced health provision  Undertaking Outcome Based in care homes Commissioning Reviews o The council’s outcome-based  Further integration between health commissioning reviews are a and social care through coordinated partnership multidisciplinary teams delivering approach to achieve the best services through networks outcomes for residents in the o Sutton has been progressing the context of the significant £22m of implementation of a locality hub savings which need to be made within Wallington with teams by the Council. Rather than from community health services simply slashing budgets the and London Borough of Sutton reviews will provide a mechanism adult social services co-located to for the Council to work with support: wider partners and to identify . a joint approach to the best way to maximise value assessments and care for residents focusing on four key planning with clear roles outcomes: Being Active; Making and responsibilities - Informed Choices; Living Well “make one visit count”. Independently and Keeping People Safe.

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o The first two of these reviews are tools and capacity to create a underway and will have Compassionate Community. significant interlinkages with the o The asset-based approach will be Sutton Health and Care Plan for designed by a diverse and example around areas such as inclusive coalition of people so social prescribing and improving that all voices within the physical wellbeing. community are heard, and the o Similarly, Sutton CCG and Epsom issues of importance to them are and St Helier Hospital Trust are addressed. working together to achieve a financial sustainable health  Engagement as partners in Improving system by developing new Healthcare Together 2020-30 models of service delivery with o The Improving Healthcare particular focus on delivering Together Programme is led by services in out of hospital the three Clinical Commissioning settings. This along with the Groups of Sutton, Merton and outcomes-based commissioning Surrey Downs with the full reviews is important to ensuring support and engagement of we get the best out of the Sutton Epsom and St Helier University pound for local people. Hospitals NHS Trust. o The programme is working with  Expansion of the compassionate all of the South West London communities’ approach within Sutton providers, NHS regulators and o In a compassionate community, the joint independent Clinical people are motivated to take Senate from London and the responsibility for and care for South East to take this work each other. A community where forward. compassion is fully alive is a o A pre-consultation business case thriving, resilient community has been developed with whose members are able to engagement from the public, confront crises with innovative residents, patients, staff and the solutions, are confident in organisations representing them. navigating changes in the o The programme plans to proceed economy and the environment to a public consultation once full and are resilient enough to engagement and assurance is bounce back. provided by all the affected o We will support individuals, stakeholders and a final business groups, and organisations to case is approved by the three develop asset base approaches Clinical Commissioning Groups. that enables them to develop the

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Our priorities, initiatives and benefits

Start well

Our priorities will be to: . decreased incidence of  improve young people’s mental health self-harm in children and  improve the support provided to young people. parents of children with Special . improved access to mental Educational Needs and Disability health support services by  develop the universal offer to make children and young people sure all children are ready for school from Black, Asian, and regardless of their socioeconomic minority ethnic groups. status . improvements in mental health and resilience We will do so by delivering the following measures. initiatives:  Continue the perinatal and infant  Implement a trailblazer enhanced mental health network (PIMH) with mental health support pilot for new projects on infant mental health, children and young people in schools, patient and public engagement, and by: fathers and partners by: o establishing a new team of o working with the Parent Infant school-based mental health Mental Health task and finish support workers in a phased group to address gaps in approach to support provision and to identify approximately 8,000 children opportunities for further across a number of schools in collaboration. Sutton. o working with the Support for o offering both one-to-one support Fathers and Partners task and and group work sessions for finish group to look at how pupils and parents, and where community assets (e.g. groups, needed, providing referrals to physical places etc) can better specialist children and adolescent support this group. mental health services. o working with Healthwatch Sutton o designing sessions to give to engage further with parents children and young people and to develop more experts by practical skills for managing a experience. range of feelings and offer o supporting the New South West parents an opportunity to London Specialist Perinatal practise the conversations that Mental Health service for encourage better mental health mothers with moderate to severe and wellbeing. mental health needs.

o This will help us to achieve a o This will help us to achieve a number of benefits including: number of benefits including:

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. Parents being able to services to the most access a service for infants vulnerable? at risk of mental health . how do we provide better issues or/and risks to their earlier interventions to brain development to improve parenting skills address needs/concerns and early literacy? identified. . how do we detect . parents and families developmental delay including those from sooner? seldom heard groups and . how do we realign Black, Asian and minority resources to meet the ethnic communities emotional needs of young engaged in testing out people? pathways and access to services. o This will help us to achieve a . experts by experience are number of benefits including: part of the network and . better universal support support work streams. for families around . services/interventions are emotional wellbeing and developed to support the parenting to improve rates needs and wellbeing of of school readiness. fathers and partners in the . earlier intervention for perinatal period. children with developmental delay /  Undertake a joint health and local SEND. authority review of our children’s . better use of resources to services, by: support more children o focusing on three key areas: with SEND in mainstream . School readiness schools. . Emotional wellbeing . more young people . Early intervention for supported at school or in children with SEND the community around o ensuring the review includes their emotional wellbeing health, education, the council and voluntary sector partners  Review and redesign the information and uses an outcomes-based and support offer for parents of approach to look at children with Special Educational understanding current need, Needs and Disability (SEND) by: assets, pathways and their o being included within the scope effectiveness before looking at of the Making Informed Choices local and national evidence of Needs Assessment, which will what works. include: o making sure the reviews tackle . completing a needs questions such as: assessment, to identify the . how do we ensure better needs of the cohort and outreach for universal demand for the services.

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. setting out a strategic working and improving care and direction in the outcomes for children. commissioning plan which will identify and assess the o This will help us to achieve a potential options that are number of benefits including: available to meet the . increased awareness of identified needs. local services offers and . implementing the agreed assets. recommendations. . improved access to . reviewing the community resources and implemented model to services leading to assess whether it is increased independence meeting the identified and satisfaction. needs and the desired . improved experiences for impact. children with Special o strengthening the advice, Educational Needs and guidance and support provided Disability and their by the SEND health team. families. o ensuring the designated clinical roles are supporting partnership

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Live well Statement that is co-produced Our priorities will be to: with providers, businesses and  improve the specialist support residents so that the local market provided for adults with learning is prepared to provide the disabilities services and opportunities  improve how we encourage adults to required and wanted by people make healthy lifestyle choices with learning disabilities in  improve the support for people with Sutton. both a long term physical and mental health condition o This will help us to achieve a number of benefits including: We will do so by delivering the following . improved experiences for initiatives: people with learning disabilities and their  Undertake a joint health and local families. authority review of how we . improved access to commission services for people with community resources and Learning Disabilities in Sutton by; services leading to o carrying out a review of Health increased independence Outcomes identified through the and satisfaction. Learning Disability Health Summit . a more sustainable, 2017 and the Joint Learning affordable and appropriate Disability Strategy 2017, and model of health and care formulating a plan to deliver for this population. person centred, community focused, integrated resources for  Review and redesign the information Sutton residents. and support offer for people with o assessing the function, structure learning disabilities by: and outcomes relating to the o being included within the scope Learning Disability Community of the Making Informed Choices Health Team, with a change and Needs Assessment, which will improvement plan to be created include: in order to deliver associated . completing a needs outcomes. assessment, to identify the o considering options for the needs of the cohort and delivery of an aligned demand for the services. commissioning structure across . setting out a strategic the Health and Social Care direction in the economy to improve efficiency commissioning plan which and to achieve associated joint will identify and assess the outcomes for Sutton residents potential options that are o developing an agreed Learning available to meet the Disability Joint commissioning identified needs. plan. . implementing the agreed o creating a Learning Disabilities recommendations. Specific Joint Market Position

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. reviewing the (prevention of heart implemented model to attacks, strokes and cases). assess whether it is . improved uptake of meeting the identified treatments proven to needs and impact. manage high risk conditions for o This will help us to achieve a cardiovascular disease. number of benefits including: . an evidence base for . improved experiences for establishing new models of people with learning care and care pathways. disabilities and their . Supporting improved work families. flow through primary care . improved access to networks to engage the community resources and skills of pharmacists, services leading to nurses and the wider increased independence primary care workforce. and satisfaction. . a streamlined, single point  Work with residents, community of access, information and groups, organisations and schools to advice offer for all promote healthy lifestyles by: residents, including people o undertaking a Being Active with learning disabilities. Outcome Based Commissioning Review with key stakeholders to  Use population health intelligence to identify and agree outcomes and more effectively identify and target interventions for increasing interventions and services for people physical activity and encouraging living with a long-term condition by: healthy living. o working with NHS England to embed the national o This will help us to achieve a cardiovascular disease number of benefits including: prevention audits . increased physical activity. o improving access to real time . improved health and data so that GPs, practices and wellbeing outcomes. networks can understand opportunities to improve care for  Improve the link between Primary patients and populations. Care and community assets to further o using audit to systematically support self-care by: identify individuals whose high- o being included within the scope risk conditions are sub-optimally of the Making Informed Choices managed, either through non- and Being Active needs diagnosis, under treatment or assessments, which will include: over treatment. . completing a needs assessment, to identify the o This will help us to achieve a needs and demand for the number of benefits including: services. . improved outcomes for . setting out a strategic patients and communities direction in the

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commissioning plan which people with diabetes and Chronic will identify and assess the Obstructive Pulmonary Disease. potential options that are available to meet the o This will help us to achieve a identified needs. number of benefits including: . implementing the agreed . improved ability for people recommendations on how with long term condition to best support and to benefit from Improving navigate people from Access to Psychological primary care to advice and Therapy interventions. services available for self- . improved health and care. wellbeing outcomes. . reviewing the . improved patient choice implemented model to (where applicable) of the assess whether it is type of intervention meeting the identified required. needs and the desired . closer collaborative impact. working between mental and physical health o This will help us to achieve a services. number of benefits including: . improved access to  Implement a Planned Care community resources and transformation programme by: services leading to o delivering Planned Care increased independence initiatives that will encompass a and satisfaction. complete transformation of how . improved health and outpatient services are used and wellbeing outcomes. delivered. This will cover all areas from demand management  Implement the integrated Improving (minimising unwarranted Access to Psychological Therapy variation wherever it exists) to (IAPT)-long term condition (LTC) usage of virtual triage, to service model by: maximising the usage of o expanding access to IAPT services community resources to be able that are integrated into primary to deliver more care closer to care offering IAPT Cognitive home. Behaviour Therapy for people with long term conditions. o This will help us to achieve a o care professionals working as number of benefits including: part of a multidisciplinary team, . improved access to with therapists who have been community resources and additionally trained in IAPT-LTC services. providing NICE-recommended . Improved waiting times for evidence-based treatments. planned care. o implementing the service in a . improved health and phased approach starting with wellbeing outcomes

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Age well  Extend the provision of social Our priorities will be to: prescribing through voluntary sector  improve how we combat loneliness organisations within Sutton by: and social isolation among older o Sutton CCG and London Borough people of Sutton working with Sutton GP  improve how we support older people Services Limited (our GP when they leave hospital Federation), Sutton Uplift, Advice Link Partnership Sutton, and We will do so by delivering the following Healthwatch Sutton, to develop a initiatives: model to support people particularly with issues that  Work with residents, community impact on their overall health groups and businesses to investigate and wellbeing e.g. social ways to leverage community capacity isolation, low mood, peer to better support people to be support, financial and housing physically, economically and socially issues. active by: o ensuring the model provides a o undertaking Making Informed tailored approach based on the Choices and Being Active needs of the individual including Outcome Based Commissioning access to advice and information, Reviews with key stakeholders to goal setting and coaching, and identify and agree outcomes and linking with community assets, specific interventions which are depending on the needs of the likely to focus on: individual. . increasing physical activity. o expanding access of social . tackling social isolation. prescribing to frail and vulnerable . developing community people through the connections. establishment of network . developing multidisciplinary team Social intergenerational support Prescribing Link workers, and to a systems through, for wider range of people through example, buddies/ the establishment of Primary mentorship schemes. Care Network Social Prescribing Link workers. o This will help us to achieve a o including the provision of social number of benefits including: prescribing within the scope of . reduced social isolation. the Being Active needs . increased physical activity. assessments, strategy . improved physical and development and procurement. mental health outcomes. . positive intergenerational o This will help us to achieve a relationships. number of benefits including: . strengthened community . improved non-medical capacity. support for people. . improved health and wellbeing outcomes.

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. improved use of capacity engagement in health- in primary care through related activities. greater self-care and . reduced emergency increased use of hospital admissions alternative services. . reduced A&E attendances.

 Extend the development of our Sutton  Further integrate pathways across Health and Care programme through Sutton Health and Care At Home implementation of a proactive model service by: of care by: o enhancing relationships between o establishing a proactive case the At Home Service and wider management approach where Sutton Health and Care Services frail and vulnerable people are through Primary Care Network proactively identified and development. supported through o reviewing the At Home Service multidisciplinary care planning rapid response admission and management to improve avoidance pathways and quality of care and to reduce enhancing as required. unnecessary hospital admissions o rolling out the Discharge to or attendances. Assess model in a phased o establishing network-based programme across all wards at St multidisciplinary teams delivering Helier Hospital. personalised care where o reviewing the capacity and professionals from a range of demand for community services including General intermediate care beds provision Practice, acute, community including the use of B6 as a post- health and mental health, social acute ward care, pharmacy and voluntary o continuing the roll out of the sector, come together to make ‘one team’ ethos throughout the decisions regarding At Home Team and wider Sutton recommended treatment and Health and Care services support for a patient. o enhancing the role of the third o developing personalised sector in supporting discharges integrated health and social care and admissions avoidance. management plans that are o using evaluation and learning electronically accessible when from Sutton at Home service needed via Coordinate My Care outcomes to inform future for professionals who need to developments for adult support those people in times of community services. crisis. o This will help us to achieve a o This will help us to achieve a number of benefits including: number of benefits including: . improved patient and . improved health and carer experience. wellbeing outcomes. . optimising independence . increased patient for people supported by activation and the service.

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. more people spending . using a Sutton GP Practice more time at home Palliative Care Register to . reduced emergency support GP Practices in hospital admissions identifying people with . reduced A&E attendances. and without cancer who . improved timely discharge may be in their last year of for people who need to be life, and to ensure that admitted. they have robust advanced care plans that are  Redesign the falls model by: reviewed on a regular o working together with key basis. partners and wider stakeholders, . working with Hospital to ensure falls prevention and Specialty Teams such as management opportunities are palliative, respiratory and maximised. renal teams to identify patients who are in the last o This will help us to achieve a stage of life whose care number of benefits including: require coordination in the . provision of an evidence- community and at home. based falls model . working with Social Care . optimising independence (council funded and self- for people supported with funders) to increase the improved health and identification of service wellbeing outcomes users (receiving social . reduced A&E attendances, funding and self-funders) unplanned admissions and who may not be visible to fractures other health and social . increased physical activity care professionals. . stronger local partnerships with wider stakeholders o This will help us to achieve a number of benefits including:  Expand delivery of the Sutton End of . patients identified as early Life care model for individuals in the as possible and offered last 12 months of life by: advanced care plans that o building on the services provided are accessible on by Sutton Health and Care Coordinate My Care. Alliance with the additional . improved patient and involvement of St Raphael’s carer experience. Hospice to provide holistic . improved outcomes with support for patients and their people achieving death in families in the last 12 months of their preferred place of their life by delivering proactive residence. case finding and/or early . reduced emergency identification to prevent hospital admissions. unnecessary hospital admissions as a result of:

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 Progress the ‘Working Together’ across South West London, functional review for delivery of including consideration of which continuing health care by: aspects of the service could be o completing the functional review best delivered: that commenced in South West o ‘At scale’ across South West London in 2018/19 on how we London commission continuing health o ‘At Place’ with a local borough care services that deliver the best focus benefits for people in Sutton and o ‘At scale’ with a borough focus . improved use of service o This will help us to achieve a capacity for patient number of benefits including: support . improved consistency in . improved capability and care delivery standards development of the and processes workforce

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6. The financial context of our plan

Good, sustainable and adaptive health and a high level of demand for Adult Social care services need to be underpinned by Care. Work to manage this demand has sustainable financial balance, however reaped benefits - however there still health and social care sectors both face remains increasing demand within this significant financial challenges. area which is reflected in the budget and Medium-Term Financial Plan. Joint working The health sector is in deficit and has been within the “Health and Social Care” system set challenging financial targets for the is crucial to improve outcomes and 2019/20 financial year. Both Sutton CCG achieve financial balance overall. and Epsom and St Helier University The Local Government Financial Hospitals NHS Trust incurred in year Settlement 2019/20 provided some deficits in the 2017/18 and 2018/19 additional funding for local government to financial years and have underlying partly help meet the significant funding deficits. pressures faced including for areas such as adults and children's services. The London Borough of Sutton, in common with other Local Authorities, has However, for Sutton as for other Local seen central government grant reductions Authorities it did not bridge the gap and these are set to continue. 2019/20 is between available resources and the the final year of the ‘4 Year Settlement funding needed to meet the increasing Offer’ from central government which demands and cost of local government provided some certainty over the resource services. In addition to that, it is unclear available to the Council. Central what is going to happen after 2019/20 government are proposing and working with this short-term funding. with local government on a fair funding review and new approach to business Sutton Council’s recommended revenue rates retention which will fundamentally budget for 2019/20 in broad terms change local government finance. includes; £4.278m of inflation, £6.247m of service growth cost pressures (including In addition, this coincides with a children’s safeguarding and adult social challenging comprehensive spending care); funded by £6.408m of proposed review where central government has savings, a general increase in Council Tax already committed a significant proportion of 2.99% that will raise £2.868m of of any increased funding available to funding, a further increase of 2.00% in protected areas. This will provide a Council Tax for the Adult Social Care challenging environment for local Precept that will raise a further £1.917m, government and the Ministry of Housing other general budget adjustments of Communities and Local Government to £0.55m, pre agreed use of reserves of advocate for additional funding for local £2.000m, and a further use of reserves of government, which is not a protected £1.089m. expenditure area. The Council financial plan over the next 3 Within the Council, consistent with the years is even more challenging. After a national picture, there has continued to be balanced budget in 2019/20, additional

28 │ SUTTON HEALTH AND CARE PLAN V1.5 savings of £12.089m in 2020/21, £5.152m in 2021/22 and a further £4.706m in We will continue to work to reduce this 2022/23 will be required to close the risk to financial targets, including working budget shortfall gap based on current to a joint financial recovery plan to get to information. Should any of the current financial balance over two years through a factors change, resulting in additional cost joint recovery programme that works to pressures or loss of further funding, then the following principles: potentially further savings will be needed.  all projects are aligned with the The proportion of these additional savings overall objectives of the Joint to be allocated to Adults Service will Financial Recovery Board depend on the budget setting process, the  the scope of each programme and outcome of the “Outcome Based associated impact is led by a Senior Commissioning Reviews” that the Council Responsible Officer is moving to and any specific changes in  all programmes build on existing work funding from the Government for the  programmes adhere to a two-year area. plan to deliver financial recovery

The new NHS Long Term Plan shows a Delivery of the Joint Financial Recovery clear intention to move towards making all Plan will be overseen by the Joint Financial NHS organisations and systems financially Recovery Board who will provide detailed sustainable within 5 years. This is scrutiny, support and challenge of quality, supported by a clear national intention innovation, productivity and prevention that local systems move to a more (QIPP) and Trust cost improvement plans transparent and collaborative approach to that require system support for delivery. planning and delivery, to reduce costs but This will ensure that there is strategic also to maintain and improve services. leadership oversight from the initiation of In Sutton there is now a clear shift towards plans (e.g. approval of business cases and collaborative working, both within the resources needed to deliver) through to health sector and with Local Authority and delivery (e.g. providing leadership for other partners in terms of planning and contingency and mitigation plans, ensuring providing services in an integrated way that lessons learned are shared and that is focused around the person. Within applied). the wider South West London footprint, Sutton is a Health and Care ‘system’, and The Joint Financial Recovery Board will be this Health and Care Plan reflects the supported by a Joint Programme joined-up system approach. Management Office who will provide the necessary programme and project Effective reduction of costs whilst management required to ensure providing quality services is possible, and successful delivery. Having this joint as such system leaders in Sutton are function will enable us to work more determined to restore and maintain effectively as a system by for example: financial balance to support and enable  streamlining our structures, processes this ambitious Health and Care Plan. and documentation Currently the risk in the health system to  providing effective joint management meet the 2019/20 financial targets is information, challenge, reporting, assessed to be at around £16m, which is a governance and assurance significant risk for Sutton.

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 leading in the joint identification and  Reducing admissions planning of benefits  Medicines optimisation  ensuring that programmes are being  Estates utilisation developed in line with agreed development principles In addition, there are four care delivery services that are expected to be As part of phase one of our recovery transferred to the Sutton Health and Care programme we have identified seven Alliance to expedite achievement of Year 1 programmes of work that we will progress of the financial recovery plan. These are to support achievement of our recovery the development of an end of life care plan, as they will either directly contribute hub, continuing health care services, a to savings or will be key enablers to review of children services, and planned success. These are: care services. Due diligence will be  Demand management – outpatients undertaken to enable transfer to the  Reducing follow-ups Alliance to commence during October  Reducing length of stay 2019.

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7. Our roadmap for delivering the Sutton Health and Care Plan

A high-level overview of some of the key delivery milestones over the next 5 years for our plan is shown below.

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