Whole Systems Integrated Care

1. Whole Systems Integrated Care Central London / Westminster Whole Systems Event – Capture of discussions 9nd April 2014

2. Who attended *No representation from the Imperial or Chelsea and Westminster Hospital

3. Participants were asked to think about the following three questions after watching ‘Sam's Story’ • Social isolation • Access to information • People falling through the net • Communication between the hospital and the GP • Lack of support when patients return home from hospital • Inter service boundaries • No coordination • Lack of good out of hours care • Financing of home care • Services are not rapid and responsive to me as a patient • Lack of dignity and respect for patients as individuals • Confidentiality – where sharing would support patients it should be made possible • Patients do not have enough control of their own destiny • Do not know / understand what services are out there and how to access them, especially within the voluntary sector • The lack of one team responsible and accountable for delivering my care plan • Many services the GP holds the ring on who is referred • Lack of support for carers • Turnover of staff • Lack of honestly and openness • Services / people need to do what they say they will do, when they say they will do it • Old attitudes, territory protection • To understand how the system works • A longer appointment with GP to discuss my complex health needs • Access to specialist professionals who understand my condition • I want to be able to plan my care • I want one person coordinating my care who understands my needs and can connect me with the right people • When I go into hospital I want to go home and do not want to go back into hospital unless my condition • I want to understand what peoples roles are and what support is available to me • I want staff to be consistent and give me the same advice regardless of who it is I am talking too • I want to know what free services can help me • I do not want my hospital appointments or operations to be cancelled as this makes me anxious • I want access to interpreter’s • I want to be able to view my record / care plan • I want a care plan that everybody follows • I want to be involved in planning and options about the care that I receive • I want to access services at a time that is convenient to me • I want my care to be right for me, not people who are like me • I want less bureaucracy, and less forms to fill in, I just want help with my care • I want professionals to explain to me what is happening • Acknowledge the role and expertise of carers, and their ability to make decisions • Trust patients and carers to know what they need and the best way to get it • Prevent peoples health from detraining • Ensure all patients with complex needs have a care plan • Increase confidence in information sharing arrangements • Being able to talk to somebody when patients feel they need too • Services that are personalised to ME • Personal decision making on what services are accessed and when they are accessed • Everybody should be able to plan their care regardless of funding and eligibility • I want one number that I can ring when I need help • End weekend delays, information readily available all the time 1 2 3 • What stops people from achieving these goals today? • Sam’s goal was to be able to live independently at home…what goals do you have for your wellbeing? • What common goals should Central London CCG / Westminster support everybody to achieve? http://www.kingsfund.org.uk/audio-video/joined-care-sams-story

4. Home based and residential What could Whole Systems Integrated Care look like in Central London? Detail based on discussions at CLCCG’s Whole Systems Event on 8th April 2014 • Text • Hospital Hospital • GP to remain responsible even when the patient is in hospital • Responsibility for admitted patients to coordinate discharge • Care plan constantly reviewed with detailing goals and wishes • Discharge planning with people from access the system, to include carers, family, care coordinator Home based and residential care • 24 hour care • Care plan constantly reviewed with detailing goals and wishes • Respite care • Domiciliary care • Pharmacist input • Formal appointment of family member to care (this to be recognised by the professionals) • Home care help and choices of time to access this home care • Supported living units • Text • Rapid response in the community • Routine care in the community • Text • Home based and residential care Routine Care in the Community • Single assessment by a nurse or Doctor • GP coordinator • Team coordinator • Flexible team to support changing patient needs • 24 hour care • More services in the community • One computer system with a good backup • Clinical care coordinator • Foot care • Minor Surgery • Phlebotomy • Inter team referral for specialist opinion • Care plan constantly reviewed with detailing goals and wishes • Service support that is flexible based on needs and changing needs • Good access to GPs • Use of pharmacists in the community • Access to equipment such as wheelchairs, and handles • Single record across H&SC • Variety of times and appointments to suit different needs • GP to plan support in advance of patients going into hospital • Establish community wards for managing long term conditions and predictable hospital admissions • Structured care plan based on wishes of the patients – not based on what is on offer • Longer GP appointments • Flexible short term input when people with fluctuating needs require it • Local diagnostic units which stop patients having to go to hospital • Co-located multidisciplinary teams located in the community which include social care • Empowerment and self care Rapid response in the community • Better access to OOH services • Care plan constantly reviewed with detailing goals and wishes • Respite Care • Access to a rapid service that is an alternative to 999 • Alert system for people involved in an individual persons care to alert to crisis or hospital admission • Access to GPs / nurses in a crisis situation • Integrated re-ablement and rehabilitation in the community • Rapid responsible available to all (mobile doctors) Empowerment and self care • Befriending • Information advice in suitable formats • Housing services • Education for self-management • Signposting to voluntary sector services • Wider voluntary support network • Integrated care plan written by myself and my career constantly reviewed includes my personal goals and wishes • Drivers / volunteers to bring patients to services • Telehealth • Education on medicines • Some services geared around improving mental wellbeing • Advice on benefits and welfare • Advice on exercise and healthy living in one place • Personal budget for those who would benefit