Integrated Health and
Wellbeing for Plymouth
A Road Map to Integrated Health and Wellbeing
“One system, one budget to deliver integrated, personal
and sustainable care”
Members Transformation Briefing, October 2014
Context for Change
Rising demand for services
Service user/patient experiences of a fragmented service
Implementation of the Health and Wellbeing strategy
Severe budget pressures
Significant health inequalities
Requirement to focus on providing Best Start to Life
Co-operative Principles and Values- “Rethinking Public
Services”
 Better Care Fund
 Political Consensus
• Integration Pioneers/Whole Person Care Council’s
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Context for ChangeInsights from co-production
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‘We need pathways that start and finish with wellness’
‘See me as a person – not a condition’
‘I want healthcare that does not stop at the boundaries’
“Carers are vital”
“Whole pathways-focus on whole person”
“Don’t be constrained by current thinking”
Integration Aims
Integration through
Transformation
Integrated Health &
Wellbeing Programme
Integrated
Commissioning
Integrated
Delivery
Children &
Young People
Care Act 2014
Integration Principles
 “One system, one budget to deliver the right care, at
the right time in the right place
 The health and wellbeing strategy will guide our future
commissioning activity
 Commissioning and Services should be integrated and
seamless wrapped around people not structured
around organisational convenience
 Decisions taken should not be done in such a way to
destabilise the other organisation
Integration Outcomes
 Provide and enable brilliant services that strive to exceed
customer expectations
 People will receive the right care, at the right time in the right
place.
 Help people take control of their lives and communities.
 Children, young people and adults are safe and confident in their
communities.
 People are treated with dignity and respect.
 Prioritise prevention
 A Sustainable Health and Wellbeing System
 Improved System Performance
Integrated Health and
Wellbeing Programme
 In July 2014 NEW Devon CCG and Plymouth City Council agreed
to:
 Pool budgets via a Section 75 agreement
 Develop single commissioning strategies for Wellness, Community
Based Care and Complex/Bed Based Care
 Work collaboratively to achieve an interim Commissioning function by
March 2015 and achieve a fully integrated commissioning function new
entity by March 2016.
 Develop Section 75 agreement to pool Adult Social Care and CCG
budgets to facilitate the creation of a community health and social care
provider
 Work with Plymouth Community Healthcare to develop options for
integrated delivery of health and social care services in April 2016
Integration Video
Integrating Delivery
through Commissioning
• Care & support will be integrated, co-ordinated around individual needs
aiming to reduce use of acute care
• Individuals who use services will be actively involved in the design of their
care
• Improved individual experience- more seamless care
• Single community provider delivering improved local health and wellbeing
• Shared commitment to common vision and goals
• Improved ability to manage whole system, reduce duplication and wastage
whilst managing variations in demand
• Evidence based commissioning driven by integrated intelligence and
information
Integrated Health and
Social Care Delivery
Bringing together…
 Adult Social Care
 Plymouth Community Healthcare
How will joined up
services address these
statements…
“I want services that support 
me to manage my situation
in life not just my condition” 
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“I want the information I 
need to make healthy
choices and stay healthy, and
to have systems in place that 
can help me at an early stage
to avoid a crisis”
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Information sharing protocol to be put in place to allow
sharing of information across wider range of organisations.
Workforce development to increase awareness of voluntary
sector and universal services available to support individuals
in the community.
Workforce development to enable staff to support plan with
individuals holistically.
Workforce development to work together with a person to
design their health and care needs support plan to best suit
their needs
Workforce development to ensure staff are up to date and
able to promote telecare / telehealth as well as support them
in accessing universal and information services.
Care Co-ordination function in place to support individuals in
managing their care
Structured care and support plans that focus on meeting
need and plan for any breakdowns
System that provides support for carers
Service accessible 24/7 capable of addressing crisis and able
to put in place immediate short term support
How will joined up
services address these
statements…
“I want the ability to talk to
a health or social care
professional when I need to
and to tell my story onceshare my information with
colleagues”
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Single Front Door into community based health and social
care
Staff working from a joined up IT system approach
Information sharing protocol to be developed to allow
sharing of information across wider range of partners
Single Assessment form that is owned by a localiy and that
allows contibutors to update / add
Access into service 24/7 at first instance
“I want to be able to have 
services provided in lots of 
different places, at a time
that suits, me having choice
and control over the care I
need”
Locality model to be created around population need
Access into service to be delivered through face to face visits,
telephone assessments and in a clinical environment working
in the best environment for the person
“I want access to a range of 
services that support me and
the people who care for me 
to lead a full and healthy life”
Commitment to increase number of carer assessments and
support
Workforce training to identify and support carers earlier
High Level Delivery
Design
111
PCC
Contact Centre
Hospital
GP
Devon Referral
Support Services
Service
Provider
Voluntary
Sector
Single Access Point
24/7
Assessment
Duty Desks
Contact Centre Pathway
Approved Mental
Health Practitioners
Home treatment
Team
Care Co-ordination
Team
District
Nurse
Out of Hours
Support Team
Rapid
Response
The principle for a single contact
Assessment response service is for
each individual to be identified
As belonging to a locality community
Or GP cluster. At the time of escalation
of urgency of needs the city wide
Rapid response function will address
The immediate need as appropriate
In a range of locations
Single Access Point Functions
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Signpost access to universal services
Arrange home visits
Invite to/or arrange MDT review
Organise care
Pass to localities
Locality Working and Case Co-ordination Organisation
Geographic Boundary
Principles
To provide a co-ordinated care and support
For individuals with health and care needs
Maximising use of assistive technology to
Promote health and wellbeing in a targeted and
Personalised way
DN Services
Community
Therapy
Social Care
GP Cluster
Long Term
Conditions
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Mental Health
Teams
Features
MDT Working principles
Patient population dashboards powered by Telehealth and
telecare
Shared assessment information
Care act compliance
Optimised usage of Case discovery and risk stratification
tools
Involvement in needs Assessment of for long term cases
Individual annual reviews
Enablers for Change
Shared Care
Records
Single Assessment
Shared Care
Records Process
Integrated IT
Joined Up Budgets
Workforce
Development
Operational
Protocols and
Procedures
Robust
Performance
Management Info
Shared Principles
and Vision
Community Benefits
 Easier and earlier access to services that promote wellbeing or that provide
help in a crisis
 People empowered to take control of their own health and wellbeing
 Local communities in Plymouth are increasingly supported by strong links
between GPs, schools, social workers and community organisations, which
helps people like them to stay independent for longer.
 Older people who have come out of hospital are helped to stay at home.
 Families and carers will not have to chase professionals or ask them to talk to
each other.
 Children with a learning disability and their families and carers are supported
in managing their needs and can trust that when they turn 25 they will
continue to receive the support they need.
 Developing social capital that enhances the lives of people in Plymouth through
providing local resources that support a greater emphasis on prevention and
early intervention.
What will local people see
as a result
 They will be able to help with designing the services they use
 They will have more care and support available at home
 They will have access to better information to assist them to
manage their own condition
 When they contact services they will only need to describe their
needs once
 The information they give to workers within the new system will
be shared so that people can make their own choices
 They will be able to speak to a professional who can help them
when they need support
 They will have the opportunity to take a lead in the on-going
shaping of services for the future
Learning from current
integrated services
Real life experiences:
Following a fall in March, Mrs P was admitted to hospital. After her
surgery she received support from the Care Co-ordination Team. A
recent interview in The Herald noted that the care provided by the
team was “wonderful”.
Mrs P has experienced joined up care and support first hand and is
really excited by the proposals to integrate all community health and
social care services….