The Model

Inclusive Economy – where everyone has a fair and real chance to access opportunities and improve their own lives

Co-operative Services – where radical innovation changes the delivery and impact of public services and

Thriving Communities – where society and social action really mean something

This model is complemented and supported by a focus on two key enablers – public service reform and empowering people and communities

#Ourbit #Yourbit #Result

Vision and ambition for improving Oldham’s population health

“Thriving Communities drawing on its own resources to stay well, and for great organised care to be available for those who need it, when they need it.”

What does this mean for Oldham People? Engaging People in the conversation The case for change

Variation in care decision-making Significant variation in care decision-making impacts quality, performance and economic stability across the Constrained funding system Constrained funding means that all partners are facing an unprecedented financial challenge, with Ageing population a forecast deficit of c. £70m by 20/21 if no action Our older population experiences is taken. multiple complex chronic conditions, with life expectancy for both men and Increasing demand women below the average. There is increasing demand from individuals Sustainability with complex health and care needs across

Integration challenge the system. Oldham experiences high levels A lack of integration between different of emergency admissions combined with providers in the system results in very increasing pressures on primary care. complex and fragmented care for those with complex needs. Children and young people Accommodation 1 in 4 of our children live in poverty. In some The volume and quality of our areas of Oldham children and young people’s community provision does not support health outcomes as worse than the national independent living as well as it could, average – performing poorly on dental health, resulting in high levels of admission to unintentional injuries and asthma in children. residential care and nursing homes. . Health and wellbeing Urgent and emergency care Our adult population is less physically active, smokes Compared to other , NWAS takes more, and carries more excess weight than the England the highest percentage of patients to A&E, while the average and we have higher than average alcohol-related second lowest percentage of calls are resolved with admissions to hospital . phone advice. What makes us Oldham: Health & Social Care

• A co-operative approach with citizens at the centre • History of making things happen in Oldham ‒ we have already invested heavily in out of hospital services (£24m recurrently) • Approach that enhances the social value by maximising the role of our Anchor organisations ‒ have strong partnership arrangements in place (the Integrated Commissioning Partnership and the Urgent Care Alliance) • A total population and system approach within our ICO with thriving communities and primary care at • Encourage cluster working in Oldham across GPs the heart taking a place based approach

• Despite a number of challenges for Localities we have • New model of system leadership with co-production made strong investment and real progress at every level (Economy, community, service users/carers, managerial and clinical staff across commissioners and providers)

Next Steps: Commissioning and Alliance arrangements 18/19

1 There will be a Strategic Joint Commissioning Board, supported by a Proposed system construct 2018/19 joint commissioning team with pooled delegated budgets through a section 75 agreement. The joint 1 NHS Oldham Oldham Council Strategic Joint commissioning team will issue an CCG Commissioning Board alliance contract to support core Section 75 providers of care to bring providers together across the system Joint Commissioning Team 2 The Alliance Contract will formalise the 2 ICO Alliance agreement between the ICO Core members Contract and the Commissioners ICO 3 3 ICO Alliance Board The Alliance Board will operate as a joint executive management team overseeing the Managed Care Organiser 4 delivery of the alliance contract Primary Mental Acute Care Health 4 Core Clusters 5 A managed care organiser function will be Providers Adult Social Community jointly created to drive system change Care Care 5 Voluntary Other Core ICO providers will be responsible for co- Sector Providers ordinating the supply and provision of care, including for patients outside of their current organisational boundaries Our journey to date

Design Investment GM Investment

Locality Case for Principles Identify Financial Agreement Plan Vision change and Care Interventions analysis Business case Pathways

System partners A shared Partners Opportunities for The impact of Locality business Investment

Journey to to Journeydate Agree the vision Understanding of collaboratively improvement that better ways of case secures GM agreement with GM for Oldham and why the system design a high-level will bring about working modelled investment funding confirmed plan for what the needs to change model for the ACS change identified Locality is seeking developed to deliver Strong track record of investment, innovation and success Oldham achievements (1)

• Establishing the primary care cluster system across the locality, completing the establishment of integrated health and care teams and creating of single structures at a GP cluster level

• Integrating services across Oldham including a fully integrated Hospital Discharge team that consists of a range of stakeholders including housing and voluntary sector representatives. This has resulted in some of the best Delayed Transfers of Care performance in

• Nationally leading performance against Better Care Fund Targets and GM leading for Delayed Transfers of Care and delivery of Personalised Budgets for patients, service users and carers Oldham achievements (2)

• Successful local performance, including:-

- The One Recovery partnership supporting those recovering from substance misuse

- Hope Citadel, with their Focused Care delivery model and their Hill Top Surgery being classed as one of the best GP practices ever visited by CQC

- Established MioCare, which provides care and support to people so they can get the most out of life by promoting independence, choice and well being

- Investment in Council Services through the Public Health transformation fund, ensuring population health goals are embedded right across the full range of Council services

Community Services & Social Care Model – Our Health & Wellbeing Board plans in Oldham Strategic Commissioner ICO Commissioning Team ICO Provider Board ASC Managing Directors for Health & Social Care Commissioning/CSS Adult Social Community Mental Health Primary Care (elements) (LCFT/OMBC/MioCare) Care Service GPs GPs 10 GPs 8 GPs 9 GPs 6 HoS Health HoS Social Care HoS Social Care HoS Social Care HoS SocialMental Care Health Mental Health HoS HealthHoS Health 11 Learning Disabilities Ops Manager Social Care Ops Manager Social Care Ops Manager Health Ops Manager Health Ops Manager Health Ops Manager Health Snr Snr Snr Snr Snr Snr Snr Snr Snr Snr PractitionerTeam LeadersPractitioner x No Practitioner Practitioner Practitioner Practitioner Practitioner Practitioner Practitioner Practitioner Health Social Care Health Social Care Health Social Care Health Social Care Health Social Care • Adult Nursing Palliative • Adult Nursing Palliative • Adult Nursing Palliative • Adult Nursing Palliative • Adult Nursing Palliative • Older People - East Care Care • Clinical Team Care Care Care • Older People - West • Social Care Lead • Social Care Lead • Social Care Team • Social Care Lead • Social Care Lead • Social Care Lead • CMHT • Senior Practitioner • Senior Practitioner • Senior Practitioner • Senior Practitioner • Senior Practitioner • AMHPs • Social Worker • Social Worker • Social Worker • Social Worker • Social Worker • EoL Social Worker • EoL Social Worker • EoL Social Worker • EoL Social Worker • EoL Social Worker • Care Coordinator • Care Coordinator • Care Coordinator • Care Coordinator • Care Coordinator • Social Worker (Review) • Social Worker (Review) • Social Worker (Review) • Social Worker (Review) • Social Worker (Review) • Care Coordinator • Care Coordinator • Care Coordinator • Care Coordinator • Care Coordinator (Review) (Review) (Review) (Review) (Review) • Social Worker (MASH) • Social Worker (MASH) • Social Worker (MASH) • Social Worker (MASH) • Social Worker (MASH) • Community Connector • Community Connector • Community Connector • Community Connector • Community Connector (Thriving Communities) (Thriving Communities) (Thriving Communities) (Thriving Communities) (Thriving Communities) • CCNT • CCNT • CCNT • CCNT • CCNT

West East Central South North Population 54,228 Population 57,789 Population 46,120 Population 44,628 Population 48,109 MioCare EDT Supported SHALD Shared LD Supported Commissioning Budget £X Commissioning Budget £X Commissioning Budget £X Commissioning Budget £X Commissioning Budget £x Housing Lives Housing

PCFT Children’s Service HoS Health Operations Manager x2 Operating Budget Total = COMMUNITY ENABLEMENT (Includes OMBC; MioCare & Pennine Care Foundation Trust) • Enablement • Help Line (24 hrs) • PCFT SPOA • IDT • HOS Health • Equipment • PCFT Rapid Response • Ops Manager Health & Social Care • Emergency Response • OOH D/N Total Staffing Compliment = 1350 Staff • Team Leaders No • Therapy Hub (Includes OMBC, MioCare & Pennine Care Foundation Trust) • Butler Green/Medlock Court • Transfers of Care (TOC)

ROYAL OLDHAM HOSPITAL - IDT Cluster Working: Glodwick

A Community Centred Approach to Population Healthcare 9 GP Practices

48,000 People The Challenges surrounding Health and Social Care in Glodwick

Education Long Term Conditions

Employment And Wealth Mental Health An award winning BME What we’ve done Type 2 Diabetes Programme so far…. Community A first language Mental Educators Health Counselling Service

Patient Health Multi Agency Working Monitoring Pods

Latent TB Screening ‘Tackling the Takeaways’ Service Initiative

Group Consultations Asset Based Community Obesity focused Development Consultation Exercise programme Cluster Working: Cluster West – Mill Town Alliance

Our Vision: Our community will have the best integrated health and social care based on local needs.

Our Purpose:

The practices of Oldham West Cluster works in an aligned and collaborative way to provide improved health care and health outcomes to the communities we support. We seek to ensure our community receives excellent care and improved health and well-being through innovative, cost effective and evidence based care as appropriate.

Cluster Working: Cluster West – Mill Town Alliance

Current Work Streams Integrated Community Services

• Children <5 service – clinical • Partnership working between support and education following Primary Care, OMBC, PCFT and A&E attendances the voluntary sector • Aligned and shared polices and • Integrated cross specialty working procedures • Cross cluster urgent appointments • Joint learning • Cross cluster minor operation • Large co-located team service • Close working with Primary Care • Cross cluster flu campaign 2018 • Integrated Community Services Oldham achievements (3)