In Brent, we are focusing initially on the development of Whole Systems Integrated Care for people aged 65 years and over who have one or more long term condition. WSIC builds on existing work to integrate health and social care in Brent and will further develop proactive identification of need, risk and instability, care planning, multidisciplinary working and the involvement of patients, carers and the voluntary and community sector, and information and data sharing. Ultimately, our goal is for anyone with complex conditions to receive integrated, proactive care.
- There are around 348,000 patients in Brent
- The borough has 67 GP practices
- The partners working together to deliver integrated care are: Brent Local Authority; Brent CCG; the Harness and Kilburn GP Networks; London North West Hospitals Trust (acute and community services); Central and North West London NHS Foundation Trust; Imperial College NHS Hospital Trust; CVS Brent and the community and voluntary sector.
The journey so far….
Our vision was developed by service-users, lay partners, frontline staff and senior leaders through well attended working groups, meetings and workshops. We have raised awareness of the Whole Systems programme whenever and wherever possible.
Just by listening, we have learnt a lot about patients' experience of Brent services and what needs to change to improve that experience. Top of the list is a simple request to be listened to, to be made aware of all the treatment, support and care services available to them and to have a say in their own care and support. This is particularly relevant for those managing long term conditions.
Patients and carers want to be supported in their homes and in local community settings as convenience and access are important. Patients and carers note that rapid, timely and responsive treatment and support in the home and community setting can avoid unnecessary and expensive hospital admissions.
We’re excited about:
- Continuing to work with the GP Networks, the council, NHS Trusts, patient organisations and the voluntary sector to develop our model of care for this population group
- Developing new structures and systems to support implementation of the new model of care
- Starting a small trial of new ways of providing care for people over 65 with long term conditions focusing first on patients from a group of practices in each Network.
- Scaling the tested model so its benefits available to all needing integrated care in Brent.