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

1. Integrated care in Westminster, Kensington & Chelsea and Hammersmith & Fulham Jenny Platt 24th June 2015

2. 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 • Types of integration could include: • Functional • Organisational • Professional • Clinical Integration between services at the same level of care i.e. primary care and community based care (and social care) Vertical Integration Integration between services at different levels in the health service i.e hospital and community [Gillies et al 1993]

3. 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

4. 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

6. 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

7. Better Care Fund (BCF) – three borough programme

8. Community Independence Service (CIS)

9. Whole Systems Integrated Care

10. Whole Systems Integrated Care

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

12. Whole Systems Integrated Care in Central London CCG

13. Whole Systems Integrated Care in Hammersmith & Fulham CCG Primary Prevention Proactive Care Coordinated Care Rehab in the community Non-Elective Admission to Hospital Primary Care Community Independence Service Residential or Nursing Home Care Adult Social Care • 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

14. 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?