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

Figure 8.28: Realising our integrated care vision
Higher
potential
value
Tactical improvement
Implement from the
beginning of 13/14, deliver
benefits in-year
1) Maximising the
potential of existing
platforms
Strategic change
Design in 13/14, implement
throughout the year, benefits
from Q4 13/14
2) Implementing an
integrated approach to
risk
3) Developing a
person-centred IT
platform to co-ordinate
care
4) Commissioning
services to improve
outcomes
Visionary thinking
Design in 13/14 for possible
implementation in 14/15,
benefits thereafter
5) Formalising whole
systems integrated
care
Slower to deliver
benefit
Whole systems integrated care
One of the key developments of the ICP in 2013/14 is the development of whole systems
integrated care.
Since August 2012, we have been working to define what whole systems integrated care
could mean, working closely with local authorities in and CCGs across Central London,
Hammersmith and Fulham, Hounslow, and West London.
The timing of this work, and many of its aims, coincided with the Tri-boroughs Community
Budget pilot. This national pilot looked at how local services can work together more
effectively, including how reimbursement models and other „rules‟ may be adapted or
changed so they can co-ordinate their work more effectively and efficiently. These two
programmes were fully aligned. Collectively, the CCGs of Central London, Hammersmith
and Fulham, Hounslow, and West London, together with the Tri-borough and members of
the wider health and social care system and representative from BEHH, set about an indepth
piece of work to define what whole systems integrated care could mean.
This work has brought together clinical commissioners, clinicians across all settings of care,
social care professionals, patients and carers and has given us unique insight into the links
between health and social care, enhancing our understanding of the potential for whole
systems. In particular, we found that 20% of patients drive 75% of demand across the health
and social care system, and were therefore priorities for any integrated approach.
We want to encourage a better way of caring for our highest risk patients. This means the
whole system (i.e. health, social care and other providers) working together differently, so
that integration and coordination becomes the norm for people who require care from more
than one organisation or service. At the heart of our approach is a simple, fundamental
8e. Delivering out of hospital care 265