SaHF DMBC Volume 1 Edition 1.1.pdf - Shaping a healthier future

around the table accelerates the understanding of what services are available and how to
access them, and allows clinicians to „short-circuit‟ unnecessary referrals and investigations.
Over the longer-term, the benefits of ICP will shift towards improved self-care and
management through the care planning process. Care planning takes place during an
extended GP consultation that involves the patient in setting goals to improve their health
and, where appropriate, puts in place contingency plans that allow patients to care for
themselves in the event of an exacerbation.
In NW London, there are currently two integrated care pilots running across all eight CCGs.
The Inner North West London (INWL) Integrated Care Pilot was formed in June 2011. It
currently covers an adult population of 635,000 across the boroughs of Westminster,
Kensington and Chelsea, Hammersmith and Fulham, Hounslow and Ealing / Acton locality.
The Outer North West London (ONWL) Integrated Care Pilot was formed in August 2012.
It currently covers a population of 1 million patients across the boroughs of Brent, Ealing,
Harrow and Hillingdon.
Both pilots follow an established 7 step process enhanced by an organisational form that
brings all of the providers across all settings of health and social care, together with patient
representatives in a provider partnership arrangement supported by legal documentation
binding the partners together, a formal agreement between the partners and the
commissioners and a hosting agreement with a provider organisation who acts as banker for
the ICP Partnership.
One unique factor of the NW London Integrated Care Pilots is the scale and pace of the
coverage that has been achieved. In the 18 months since the first pilot was established the
population coverage is now close to 2 million people, with provider partners across NW
London working in multi-disciplinary groups.
In the feedback from the Royal Borough of Kensington and Chelsea Health, Environmental
Health and Adult Social Care Scrutiny Committee feedback they asked for further details of
the achievements of the ICPs. This information is provided in the following sections.
Inner North West London ICP: achievements in 2012/13
The Inner North West London Integrated Care Pilot was an ambitious programme set up in
June 2011 to engage a range of health and social care providers and GP Practices across
Inner North West London in collaborative and proactive working for a defined and targeted
group of higher risk patients. Much of year one concerned the mobilisation of the pilot in
terms of developing clinical pathways, forming multi-disciplinary groups and implementing
the IT tool. In year two, significant progress has been made in establishing and bedding
down the pilot. There are now 13 MDG Groups operating and they have held 200 case
conferences, discussing some 1,350 cases, with attendance between 75–80% across all
partners. Case conferences now discuss an average of 10 patients in each meeting.
GPs have created 21,000 care plans for higher risk elderly and diabetic patients and there
has been a significant increase in dementia diagnosis, which the independent evaluation
was felt to relate to the increase in care planning .The care planning process has been
positively evaluated through the patient survey which took place as part of the evaluation,
citing that they had been involved in the undertaking of their care plan, and had improved
access to NHS services as a result of the care plan. In June 2012, the existing pathways
were refreshed, and in addition the Inner pilot worked with the Outer Pilot on two new
pathways.
8e. Delivering out of hospital care 261