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Pioneering Whole Systems Integrated Care A view from North West London

Pioneering Whole Systems Integrated Care A view from North West London. Caroline Bailey – Assistant Director, NWL Collaboration of CCGs John Norton – Lay Partner, Embedding Partnerships Stephen Day – Director of Adults Services, London Borough of Ealing. NCAS – 29 October 2014.

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Pioneering Whole Systems Integrated Care A view from North West London

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  1. Pioneering Whole Systems Integrated CareA view from North West London Caroline Bailey – Assistant Director, NWL Collaboration of CCGs John Norton – Lay Partner, Embedding Partnerships Stephen Day – Director of Adults Services, London Borough of Ealing NCAS – 29October 2014

  2. North West London covers two million people and has committed to an ambitious out of hospital strategy • North West London 2 million people 8local boroughs 8 CCGs Over £4bn annual health and care spend Over 400 GP practices 10 acute and specialist hospital trusts 2mental health trusts 2community health trusts

  3. Now Whole Systems Integrated Care is integral to our plans for transformation • “ Our shared vision of the WSIC programme … … supported by 3 key principles • 1 • 2 • 3 • We want to improve the quality of care for individuals, carers and families, empowering and supporting people to maintain independence and to lead full lives as active participants in their community • People will be empowered to direct their care and support and to receive the care they need in their homes or local community. • GPs will be at the centre of organising and coordinating people’s care. • Our systems will enable and not hinder the provision of integrated care. • ”

  4. We developed a framework to guide us through answering the difficult questions • Scope • Commissioning • Provider • Funding mechanism • Investment and risk is shared through capitated budgets What services could providers provide better if they work together? How do different providers of care decide to spend money in new ways? • Which groups of people should we organise care around? • How do we bring existing resource together to deliver the goals that matter? • Capitation allocation used by providers to cover all service user care • What goals do people in those groups want to achieve • Outcomes: • People empowered to direct their care and support and to receive the care they need in their homes or local community

  5. Pioneer status gave us the momentum and mandate to bring partners across the system together and help answer those questions

  6. Lay partners… • … bring courage and encouragement • … are whole life assets • … push for blue sky thinking • … hold projects to account • … maintain a health tension between delivery and co-design • … bring patients to the centre • … embed insights and expertise from different backgrounds • … influence and challenge language and behaviour Lay Partners are “guardians of the vision”

  7. Lay partners are now defining the outcomes that WSIC models of care need to achieve and how they should achieve them • “ • Service users and carers must be able to trust the system • “ • There is full continuity of care for service users via named people • ” • “ • Users and carers are empowered, supported and can access appropriate education • ” • “ • A common, simple language is used • ” • ”

  8. We have put the content from the co-design phase into a ‘Whole Systems Toolkit’ integration.healthiernorthwestlondon.nhs.uk

  9. Across NWL ‘Early Adopters’ consisting of commissioners and providers are planning the implementation of Whole Systems Integrated Care

  10. Whole Systems Integration journey in Ealing 2015/16 2012/14 2014/15 Integration Programme Implementation Integration Programme Mobilisation • Model of Care revised following evaluation • Healthy at Home Scheme starts (Funded by BCF) • Identification of virtual capitated budget • Options for an Accountable Care Partnership Pioneer Status: Vision, Principles & Approach across NW London Integrated Care Pilot • ONE INTEGRATED PLAN to deliver change (including outline plan for 75+ with LTCs) • Begin implementation of agreed schemes / prototypes • Creation of Joint management team (LA/CCG) • Joint Programme Management Office • Evaluation of prototypes 79 GP’s grouped into 7 Multidisciplinary Groups (social workers, community health, acute) • High risk cases assessed monthly across all networks through Care Planning Better Care Fund requirements Embedding Partnerships/Patient and Public engagement Commissioning governance & finance Key features of our Integrated care model Population and Outcomes / Care coordination & navigation Provider and GP networks Information

  11. Ealing Model of Care • Aligning nursing and social work team structures to GP localities • Target population group - the over 75s with one or more long term health condition • Teams supported by care coordinators and care navigators

  12. Healthy at Home: working towards a new configuration of intermediate care services

  13. Questions ?

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