What have we achieved already?

Section 4

In recent years, there has been considerable effort to transform the health and care system in this direction. The NHS and local authorities in North West London have launched multiple initiatives aimed at improving the quality and efficiency of care provided outside hospital, laying strong foundations upon which integrated care can be built.

Reflecting the diversity of the different boroughs, the schemes that have been developed vary widely in the populations they target, the design of the programme, and the stage of implementation:

In Central London, the patient referral service has seen a shift from 48% of outpatient referrals taking place in community settings to 54%, and an overall reduction in referrals of 11%. More than 2000 care plans have been created through the Well Watch programme since its launch in June. To cope with busy winter periods, there is now seven-day access at 5 GP practices in addition to extended hours for additional GP appointments and duty clinicians to allow earlier home visits if required. Integrated working has already started, with the establishment of sub-locality units that bring together GPs, other health- and social-care professionals to take shared responsibility for care, and many practices have signed up to a new, single IT system that will aid integration.

West London’s unscheduled care projects are all on track, with Putting Patients First (PPF) integrated care scheme now incorporating the Integrated Care Pilot (ICP). This improves our ability to case manage people at risk of hospital admission. It also encourages greater use of rapid response and community independence services to support people in the community. All 54 local GP practices have signed up to this approach. The principles around the framework are care planning, integrated case management and multi professional input. All practices will have a monthly Multi-Disciplinary Team meeting (MDT) with a Community Nurse, Social-care Worker and a Mental-health practitioner in attendance. Around 70% of practices are having regular (MDTs). The hospital avoidance system addressed 966 people in the first six months after it was launched in April 2012, helping to avoid 166 admissions each month. Extending proactive case management has meant that 80% of unplanned admissions are from those without care coordination.

In Hammersmith & Fulham, health- and social-care co-ordinators are improving the quality of care co-ordination for people discharged from hospital with particular focus on frequent attenders to hospitals. At the same time, GPs have seen the impact of high quality care planning and the hospital at-home service, which are helping to avoid admissions. Key achievements have been the development of the Community Independence Service which supports our Virtual Ward function by bringing together Acute, Community and Social-care professionals to work as one team under the umbrella of our GP networks. In addition, The Parkview Centre for Health and Well-being is on schedule to receive its first patients in Spring 2014. Based on Bloemfontein Road W12, People will be able to access a wide range of service including primary care, specialist dental and child development services as well as specialist services for people with long-term conditions such as diabetes, COPD (chronic obstructive pulmonary disease) and heart conditions.

Hounslow’s integrated community response service received more than ~100 referrals in a single month alone, helping to avoid admission into hospital. The referral facilitation service has reduced admissions and lightened the administrative burden on practices. As a consequence, 90% of the initial investment was recouped in its first year of operation. Hounslow’s targeted care of people with diabetes as an area of improvement. We have increased the number of educational training slots for people to learn how to manage their diabetes and are on target to educate 800 people this year. We have been steadily increasing our diabetic consultant capacity from half a day a week since early 2011, to one day per week in early 2012 and now to two days per week in 2013. The consultant plays a crucial role in leading and developing the intermediate service. By Autumn 2014, the CCG will have procured a new diabetes intermediate care service to deliver a much more integrated service including treatment, education and foot health.

Ealing’s new Pulmonary Rehabilitation Service has served 400 people in its first year of operation. It is an integrated, 6 week programme of exercise, education and advice on self-management that has seen 75% of people have a measurable physical improvement in symptoms. In addition, Ealing has also rolled out £400k in organisational development funding for primary care networks, and £1.2m in funding for extra community general short term beds at Claypond’s Hospital. Ealing has also supported 7 day working for social services, covering weekends and evenings, and the integrated care service working across health- and social-care provides rapid assessment and response and short term rehabilitation in the community, and has prevented more than 1,000 hospital admissions since its inception.

Hillingdon’s Rapid Response Team has extended its services since May 2012 to the Accident and Emergency department at Hillingdon Hospital, 7 days a week. By working closely with the Hospital staff, the team have been identifying people with conditions that can be treated quickly or can be treated in North West London Whole Systems Integrated Care Toolkit their own home with the right support, avoiding their admission to Hospital and providing a much better experience for the patient. In addition, the Hillingdon Musculoskeletal Clinical assessment and treatment service, launched in April 2013, has increased patient satisfaction through more integrated working for rapid assessment. Finally, Hillingdon has launched the "Right Care, Right Place” booklet to educate people about how to access the right care for them in the most low-intensity setting.

Harrow Council and the local NHS have been working in close collaboration to develop an innovative new service which enhances the work already being carried out in Primary and Secondary care, to provide the right care in the right place at the right time. A programme called the "Frequent Attenders Reablement Project” provided a range of individualised support to older people to increase their independence and reduce their anxiety on a range of health conditions. Commissioning a new ambulatory emergency care unit at Northwick Park Hospital. This currently provides ten types of treatments to reduce the need for a short stay admission to hospital by treating in a high intensive day case setting. In 2014 we plan to expand this service to provide a further seven treatments which will include chest pain, asthma and falls.

In Brent, five GP localities offering expanded services and extended hours are already set up and functioning. Cardiology and ophthalmology services are being shifted to community settings to relieve pressure on acute settings, and musculoskeletal and gynaecology services will soon be moved in the same way. A psychiatric liaison service has been set up to consult with staff in urgent care centres and A&E, and there are single point of access and supported discharge programmes operating for mental-health services as well. These teams include professionals from hospitals, mental-health trusts, social-care and voluntary services. In addition, the short term assessment rehabilitation and reablement service (STARRS) offers integrated support for people who are ready to be discharged from A&E at Northwick Park Hospital but may require extra support once at home. Social workers and GPs work with STARRS therapists and nurses, as well as the A&E staff, to identify people who would benefit from the integrated service.

At the same time, the Integrated Care Pilot has been launched across all eight boroughs, split into inner and outer boroughs. Established in July 2011, the Integrated Care Pilot is a provider-led initiative serving North West London’s entire population of two million people. It involves professionals from community health, mental-health, primary care, secondary care, social-care, community pharmacy and specialist nursing coming together with patients and carers to realise a shared vision of high quality services.

Enabled by a unique data warehouse which links and shares provider information, the ICP identifies people with the most complex health- and social-care needs and stratifies risk. Providers can then come together to co-create integrated and proactive care plans tailored to individual need. A bespoke IT tool enables patients, as well as professionals, to access their own health data and take ownership of their care plan.

Multi-disciplinary groups (MDGs) meet monthly with the aim of improving the care of individuals with complex needs. As well as providing significant benefits for patients, the MDGs have encouraged more collaborative working, shared learning and closer relationships between care providers. Significant investment in senior leadership and dedicated programme support has played a major role in driving the ICP’s success, along with the active involvement of patients and carers including large-scale simulation events run by patients for professionals. We have also identified additional benefits beyond the original objectives, for example notably improved awareness of available local services.

To date, across the pilot as a whole:

  • 62,000 care plans have been created
  • 650 case conferences have been held
  • 4,300 individuals have been discussed
  • 6% of projected non-elective admissions have been avoided

The integrated care pilot has forged stronger relationships between different parts of the clinical community. Meeting regularly in case conferences to discuss specific individuals has created new bonds between different professional groups.

We need to maintain and build the momentum generated by the pilots to navigate the changing government landscape and to deliver truly transformational Whole Systems Integrated Care for our population in North West London.