Integrated Care

Joined up, or ‘integrated care’, is a term we used to describe a process which makes it easier for health professionals from the NHS and social care professionals from council run services to work more closely and effectively together.

With an increasing number of people living longer in North West London and needing support and treatment for a number of different conditions, more and more people now receive care and support from several different doctors, social care staff and/or specialists.

That’s why it’s important that now, more than ever, health and care systems in North West London become more joined up and easier to navigate for anyone that needs them.

Today, health and social care is delivered by different organisations that work separately. Patients told us they were fed up with having to repeat the same information to different doctors or carers.

We are working to change this by putting people and their goals at the centre of a team of health and care professionals who work together smoothly, with a single approach.

Our Whole Systems Integrated Care (WSIC) programme is about giving people more say over their care, when and where they receive it, so that care is planned jointly between patients, their carers and the teams that support them.

By involving patients and carers on the journey from day one, we have a much better chance of achieving our vision: care that enables each of us to help ourselves. And by widening access to services that aren’t necessarily provided by the NHS, such as local buddying schemes and exercise groups run by third sector parties, we can better support people to maintain independence and lead full lives as active participants in their communities.

In North West London, we were selected as one of initially only 14 areas nationally to become a pioneer in integrated care. After a bidding process which attracted around 100 entrants across the country, we were chosen because of our commitment to working at pace and scale to provide joined up care to our two million residents.

It means that the eight CCGs across North West London are now receiving specially-tailored support from NHS England, including access to specialists in innovation and change from NHS IQ (Improving Quality), to accelerate further the process of enabling more integrated, user-centred care.

For local people, it means they will:

  • Benefit from much closer working between all parts of the health and social care system.
  • Have more say over their care and when, where and how they receive it.
  • Have a greater variety of more convenient ways of accessing advice and care from different providers.
  • Have a clear plan, developed with their input, to get the best treatment and achieve the goals that matter most to them
  • Find it easier to navigate their way through the care system.

Each of the eight localities are responsible for delivering services that meet the needs of their population. However, in the past organisational and geographic boundaries have created challenges for integrated care. Whole Systems Integrated Care aims to remove these barriers through better use of multi-disciplinary working and care planning.

The first step of the journey started with more than 200 health and social care professionals, alongside people who use services across North West London, coming together to share knowledge and develop solutions together to deliver better joined up care. This overarching commitment to co-production ensured that service users – lay partners – were embedded within the working groups with a ‘Lay Partners Advisory Group’ overseeing and challenging the programme’s approach to engagement.

The result of this first stage has been to produce an innovative integrated care toolkit for use by partners across North West London to help them plan improved ways of delivering care and support in their local areas. Providing information on populations, models of care, commissioning, GP networks and informatics, the toolkit is a living document that will continue to evolve as local areas implement their plans and lessons are learnt, and we continue to welcome comments and contributions from all.

Nine ‘early adopters’ – local partnerships of health and social care commissioners and providers – are now leading the way in using the co-designed toolkit to implement integrated care across North West London.

Our integrated early adopters and their areas of work are:

  • Brent – starting a trial of new ways of providing care for people aged 65 and above with long-term conditions
  • Central London – set up a provider network to make decisions about how they can work together and monitor success and established care co-ordinators to act as a point of contact for patients and whose role will be developed further
  • Ealing – initial model of care roll-out in Central Ealing GP networks, with a focus on people aged 65 and above with long-term conditions
  • Hammersmith and Fulham – focusing on person-centred, not illness-centred, services for older people and developing these more closely with lay partners
  • Harrow – implementing a Virtual Ward to provide integrated, urgent anticipatory care for people aged 65 and above with long-term conditions
  • Hillingdon – developing integrated care services for people aged 65 and above with long-term conditions, working closely with local organisations and the voluntary sector
  • Hounslow – provided social workers in five localities to deliver new integrated model of care which will be built upon and launched a new Community Respiratory Service
  • West London – working with patients, front line staff and carers to design and deliver a new system of care for people aged 65 and above in Kensington, Chelsea, Queen’s Park and Paddington
  • Mental Health – delivering projects to improve outcomes for severe and enduring mental illness population in a GP network in Hounslow and across West London

To make sure this collaboration happens consistently, we’re removing funding barriers in the system by developing plans for capitated budgets. This gives providers the freedom to move resources to where they are most effective, such as greater involvement of third sector parties in delivering care, or more flexible ways of working with specialists who are currently based in hospitals.

Information sharing

Information sharing is an important part of integrated care as it makes it easier for health and social care professionals to work together.

It means that those involved in a person’s care can see relevant information about their diagnosis, treatment and care, so they can receive support which is more closely tailored to their needs.

This ensures that when a person visits their GP practice, the hospital or gets support in their community or at home, care professionals such as your GP, hospital doctor, district nurse, therapist or social worker have the right information at the right time.

Shared information includes:

  • Your NHS number, age, contact details and next of kin
  • Appointments, treatment and care
  • Test results such as blood test, laboratory tests, X-rays
  • Medications and allergies
  • Health and wellbeing information relevant to your care

Who will see information which has been shared?

  • Health and social care professionals such as GPs, nurses and social workers directly involved in delivering your care.
  • Support staff organising appointments and treatment
  • Health and social care teams discussing diagnosis, treatment and care at case conference

Supporting and improving care

Some information without personal details may be shared securely with health and social care organisations to plan and improve local services for the people of North West London. This anonymous information helps to anticipate, plan and provide care. It also helps us to monitor the quality of services provided.

You can opt-out (stop) from sharing your information at any time. If you want to opt-out, please tell your health or care organisation providing care to you.

Your Neighbourhood Professionals. Just a Click Away! BMI The Clementine Churchill Hospital
Your Neighbourhood Professionals. Just a Click Away! BMI The Clementine Churchill Hospital