Integrated care in Westminster, Kensington & Chelsea and Hammersmith & Fulham

Jenny Platt

24th June 2015

What is integrated care?

Integrated care: an organising principle for care delivery with the aim of achieving improve patient care through better coordination

Integration: methods, processes, and models that help to deliver this

Horizontal Integration

Vertical

Integ

ration

Integration between services at different levels

in the health service i.e hospital and community

Integration between services at the same level of care i.e. primary care

and community based care (and social care)

Types of integration could include:

• Functional• Organisational• Professional• Clinical

[Gillies et al 1993]

What are the benefits of integrated care?

For people, patients, customers:

National Voices produced a set of “I” statements to describe the patients/users perspective on integrated care:

“I can plan my care with people who, work together to understand me and my, carer(s), allow me control, and bring together services to achieve the

outcomes important to, me.”

Economic, system benefits:

A mixed evidence base in the UK, with some stronger international evidence

• Reducing unnecessary hospital admissions and A&E attendances• Reducing ambulance call outs• Reducing length of stay in hospital • Reduced duplication and improved efficiency (workforce)• Improved quality and clinical outcomes

NHS England Five Year Forward View

• Recognises the NHS needs to evolve to meet new challenges – people living longer with more complex needs – and to benefit from opportunities from science and technology

• This must be done in partnership with local communities, local authorities and employers

• To establish a more engaged relationship with patients, carers, and citizens – promote wellbeing and prevent ill health

• People need to have greater control over their care

• Barriers in how care is provided must be broken down

• Different models of care will emerge

• Multispecialty Community Provider• Primary and Acute Care Systems

Better Care Fund (BCF)

• The BCF is a single pooled budget for health and social care services to support transformation and integration of service to ensure local people receive better care. It is based on a plan agreed between the NHS and local authorities.

• The BCF is a pooled budget that shifts resources into social care and community services for the benefit of the NHS and local government. National funding of £3.8bn was announced in the summer of 2013 to support this initiative.

• The three CCGs and Local Authorities have agreed a joint plan which covers £192m of expenditure across existing services and investment.

• Measured against an agreed target of reduced unnecessary hospital admissions

Better Care Fund (BCF) – three borough programme

Community Independence Service (CIS)

Whole Systems Integrated Care

Whole Systems Integrated Care

Whole Systems Integrated in West London CCG (K&C and QPP)

Whole Systems Integrated Care in Central London CCG

Whole Systems Integrated Care in Hammersmith & Fulham CCG

Coordinated CareProactive CarePrimary Prevention

Community Independence

Service

Primary CareRehab in the community

Residential or Nursing Home

CareAdult Social Care

Non-Elective Admission to

Hospital

• Social prescribing pilots• Expanding case management and multi-disciplinary working in

primary care• Developing a consistent model for End of Life care, working closely

with the Community Independence Service

What role can care and support providers have in integrated services and new models of care?

What further information would you like to have and how would you like to be involved?