Better integration of care for diabetes and older people in North West London

Leading the way in NHS modernisation, organisations across both health and social care in North West London launched an Integrated Care Pilot on Wednesday 8 June in the same week that the Government announced integrated care is to be one of the fundamental priorities in the future of the NHS.

This pilot intends to integrate the care of people who are aged over 75 or who have diabetes from an initial population of 375,000. It has been clinically led by GPs, hospital doctors and community care professionals to develop a way to provide delivery of highly co-ordinated and patient-centred care. This model is unique to previous efforts—it involves more partners than ever before sharing both risk and benefit equally from reward.

Professor Chris Ham, Chief Executive of The King’s Fund, said of the pilot: “Clinically integrated care offers real benefits for patients and helps to ensure that resources are used efficiently. The North West London Integrated Care Pilot provides an opportunity to demonstrate these benefits for people with diabetes and frail older people. Its progress will be watched carefully as the NHS rises to the twin challenges of an ageing population and the increased prevalence of chronic disease.”

By working in an innovative way patients will see their GP work more closely with hospital doctors and social care teams (if necessary) to understand their needs and plan the best care. The aim is to improve patient experience, ensure consistent use of guidelines to promote best practice, strengthen support care co-ordination across care pathways, reduce unwarranted variations or gaps in care, and prevent admissions to hospitals and nursing homes through management of long-term conditions within primary care settings.

Central to achieving this will be aligned financial incentives that support providers to work collaboratively by avoiding any perverse effects of activity-based payments.

The North West London Integrated Care Pilot begins this month and runs for a year, serving patients from Westminster, Kensington and Chelsea, Hammersmith and Fulham, Hounslow and Ealing. It lifts the boundaries between hospitals, community care services, social care and local authority to allow faster access for patients and a stronger focus on their long-term needs.

Through integrated care, providers can work together as a team so that patients receive the right kind of treatment in the right place at the right time. Partners leading the pilot have expressed their strong support for the initiative and the benefits in moving from recognised best practice to working together in reality for the greater good of North West London residents.

Heather Lawrence OBE, Chief Executive of Chelsea and Westminster Hospital NHS Foundation Trust said: “High quality care is dependent on organisations working seamlessly to provide patient centred care. The Integrated Care Pilot seeks to join up providers in North West London to provide integrated care to people with diabetes and the frail elderly. Chelsea and Westminster Hospital NHS Foundation Trust is proud to join the Integrated Care Pilot in the second wave.”

Dr Iñaki Bovill, Consultant Physician and Geriatrician at Chelsea and Westminster Hospital said: “The Integrated Care Pilot aims to link up primary, secondary and tertiary care for diabetic and elderly patients. The patients’ needs will be at the centre of this process and will be the focus and driver for it. Planning care across provider borders and sharing the necessary information will enable us to pro-actively care for frail elderly to prevent them slipping down the scale.”

Anne Rainsberry, Chief Executive of NHS North West London said: “We are delighted to be part of such a pioneering initiative for North West London. This pilot lays down key elements that are needed to make integrated care work, such as a collaborative culture where providers work together towards common goals, the involvement of patients making decisions about their own care and clinical leadership. We are confident that this approach will result in success and benefit all those involved.”

Mark Davies, Chief Executive of Imperial College Healthcare NHS Trust said: “This completely new way of working will see health professionals from each part of these patients’ pathways come together to provide truly integrated care. By breaking down artificial barriers across different parts of the health service, we aim to offer higher quality care in the most appropriate setting and improve the patient experience.”

James Reilly, Chief Executive of Central London Community Healthcare NHS Trust said: “The Integrated Care Pilot is unique in that it builds capability for primary, community and healthcare services to work collaboratively to safely support people at home, thus reducing unnecessary hospital stays. It is a direct response to patients and carers who seek more seamless, joined-up healthcare delivery. We at CLCH, as the host for the pilot, wholeheartedly embrace this opportunity to provide the best quality patient centred care.”