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

integrated care envisaged in the business case is now an operational reality. In addition to
mobilisation, a number of important early benefits have been realised.
From a standing start, the ICP now covers a population base of 1 million. Of this population,
113,000 fall within the current criteria for receiving integrated care. This scale of population
coverage represents a significant achievement for the ICP.
This extensive population coverage was made possible by the rapid implementation of multidisciplinary
groups, which leverage the GP networks being formed across NW London. ICP
members made the decision that it was most logical to build on these existing networks for
their operating model, rather than creating something new and different. In addition to
enabling a more rapid implementation than would otherwise have been possible, this
approach also offers the potential for useful synergies between the ICP and other parts of a
network‟s activity to emerge.
The pilot is at a sufficiently early stage that it remains too soon to establish its impact on
non-elective admissions in a statistically robust manner. However, the ICP has already
delivered a range of important outcomes and benefits.
Initial evidence suggests that the risk stratification approach has been
successful, both in terms of identifying high-risk patients but also in changing clinical
practice based on the information
Patients welcome the opportunity to proactively plan their care, and 96% of
patients surveyed think that having the care planning discussion has helped improve
how they manage their health problem
An audit of care plans showed evidence of improvements to care, including
consistent screening for common problems, detection of previously unknown clinical
or social problems and proactive discussion about how to manage health in the
future
The actions arising from care plans are themselves integrated, with 28% relating
to social care, 15% to mental health and 57% to other providers. These integrated
actions generate integrated responses
Through the ICP, formal and informal networks have been developed that can
improve patient care. Some 91% of attendees at case conference report that they
have developed relationships that improve the way they are able to care for patients.
Moreover, 65% of attendees say they have changed their clinical practice as a result
of attending a case conference and 67% believe that the advice they gave or
received as part of a case conference would help to reduce non elective admissions.
Attendees at multi-disciplinary groups have been able to learn more about the local
services available, and 71% of attendees at MDGs having learned about new
services in their Boroughs through attendance at case conferences.
Developing integrated care in 2013/14
It is significant to note how far the formal evaluation of the INWL ICP mirrors the ongoing
evaluation of the ONWL ICP in terms of early improvements for patients, carers and health
and social care professionals, future opportunities to move further and faster towards
population-based integration and the need to see the ICP approach as a component of a
wider system response to integration. The business plan for both ICPs in 2013/14 will focus
on five key themes which together address the requirements described previously, while
crucially also helping move towards a truly whole systems approach to integrated care.
Figure 8.28 summarises the key priorities for integrated care from 13/14.
8e. Delivering out of hospital care 264