A 2013 pioneer programme unites care providers together and enables Kent to improve patient care
Kent’s integration pioneers programme is a whole system partnership involving Kent’s seven clinical commissioning groups (CCGs), Kent County Council’s (KCC’s) adult social care teams, community, acute and mental health providers, ambulance trust, public health, voluntary and social care providers and HealthWatch. The steering group is a working group of the Kent Health and Wellbeing Board.
Our approach to integration is about local delivery and, as Kent is a large county, we have worked hard to bring stakeholders together and develop a shared vision to put the citizen at the centre of everything we do, with services wrapped around them providing support when they need it, within their communities.
Prior to becoming a pioneer, Kent was working on health and social care integration and had many initiatives in place that were working successfully. However, we wanted to increase the pace and scale of what we were doing and thought that becoming a pioneer would be a good vehicle to do this. We are also keen to share the learning we are gaining with others nationally and internationally and have also created more resources to help organisations work together.
The Kent innovation hub
This is a way of making sure we can communicate effectively with each other. Most activity is hosted virtually through Twitter chats and webinars, with additional workshops and conferences being developed with a focus on the themes that support our work.
These are being set up in different localities to promote innovation and enable transformation of the workforce to meet the changing needs of our communities including using technology in new ways. Networking across these “labs” will share learning and disseminate good practice at pace and scale including close collaboration with our vanguard multi-specialty community provider site based in Whitstable.
European Union (EU) and international work
Kent is leading for the national pioneers on EU and international engagement and will feed back to the national integration pioneers assembly (an event to mark one year of pioneers). There are many opportunities to learn and get resources from the EU – Kent has many international partners as well as an international team based in Brussels and strong links with the International Health Alliance. Japan, USA and New Zealand are other countries that are increasingly working with Kent.
We have achieved a great deal in a short time, including setting up integrated discharge teams in hospitals, teams in the community to proactively work with patients most at risk of becoming ill, integrating computer systems to make it possible for hospitals and other clinicians treating a patient to see their GP record or care plan, and working with communities to understand their health and social care needs.
What are we doing across the county?
NHS Dartford, Gravesham and Swanley CCG and NHS Swale CCG have been working together to create a more coherent and sustainable integrated health and care service that puts the patient first.
Integrated primary care teams are being introduced around GP surgeries to ensure people who are most at risk of falling ill and/or losing their independence receive the best care they need to support them at home. The team will plan care together and share their expertise and knowledge to avoid duplication and the frustration of patients having to make multiple visits to see different clinicians. The key focus of this team is to provide whole person care in a way that maximises their independence.
One of the most successful projects has been the introduction of an integrated discharge team in Darent Valley Hospital. Datford, Gravesham and Swanley CCG commissioned team brings together primary care (GPs), acute, community, mental health and social care professionals who work together with the voluntary sector to help assess, treat and safely discharge the elderly, patients with mental health needs, and those with long-term conditions.
Darent Valley Hospital was one of the country’s best performing hospitals this winter in meeting the four-hour target. It is estimated that the integrated discharge team prevents up to 10 unnecessary emergency admissions to the hospital every day. Since January 2014, no patient has been admitted into long-term residential or nursing care from this trust and 95% of patients have been successfully discharged to their own place of residence.
NHS South Kent Coast CCG
NHS South Kent Coast members are coming together to lead the formation of a multi-speciality community provider for the local model for health and care services, out of an acute hospital setting, wrapped around the patient, and co-ordinated by their GP.
The CCG’s membership is working with more than 200 clinicians, professionals and local people to finalise the design of services that each community needs. Promoting prevention and self-care is a key focus along with ensuring that those who are the most vulnerable and those with complex long-term conditions receive holistic packages of coordinated care. Members have used the Prime Minister’s Challenge Fund to test their approach in two local communities. The CCG is one of nine pilot sites nationally to test personal health budgets for people other than those needing continuing healthcare. With KCC, integrated personal budgets have been offered to patients so they can buy services to meet their health and social care needs. These enable people to take control of their health and social care support in a way that meets their identified needs.
NHS Thanet CCG
NHS Thanet CCG members are coming together to lead the formation of a multi-speciality community provider for the local model for health and care services. This will be arranged around the patient and co-ordinated by their GP. With an ‘island’ geography including a small hospital – they are looking to develop the model to include community orientation (where a doctor identifies characteristics of the local community that might impact on patient care and encourages patients to use resources appropriately) of this facility.
In addition, the CCG is working with Social Enterprise Kent on the Ageless Thanet project. This is a partnership of voluntary, statutory and private sector organisations, which will deliver high-quality services for older people to improve their quality of life, physical and mental wellbeing and reduce loneliness and social isolation.
It is also now possible for east Kent hospital clinicians treating a patient to see their GP record, with their permission, and in the future access could be extended.
NHS Canterbury and Coastal CCG and NHS Ashford CCG
Both CCGs have established a framework for commissioning community-based services to ensure that health, social care and voluntary services are based around individuals and the communities in which they live and often work. The framework – called Community Networks – is focussed around GP practices and their communities. The framework will be used to commission an integrated suite of health, social and voluntary services from local providers within a defined budget but with a greater focus on patient outcomes.
Patients, service users, providers and partner organisations will be involved in selecting and designing these services, which will be based on the needs of the local population.
To support the work of the community networks, the CCGs’ value for money process is underway. This is a collaborative approach with providers where the effectiveness of a number of historically commissioned community-based contracts will be reviewed. The results will be used by the community networks. The CCGs are also working with NHS Right Care to highlight where further transformation and improvement can be made.
A good example of the community network approach is the establishment of Health and Social Care coordinators who provide an essential link between GPs and community services. In addition, the Medical interoperability gateway is being rolled out across practices so electronic patient information can be shared between secondary and primary care organisations.
NHS West Kent CCG
Four thousand patients have been seen by west Kent’s enhanced integrated rapid response service since it started. The service offers support from a multi-disciplinary team that works with the ambulance service to ensure that people are not unnecessarily admitted to hospital and are supported on discharge from hospital. The key to the success of the service is the collaborative working between health, social care and ambulance services providing a fast response to patients. The service particularly targets people aged 75 and over and includes clinical treatment, rehabilitation and support.The CCG has commissioned a new IT system to enable shared viewing of patients’ care plans by all those treating them, including hospital staff, hospices, ambulance crews and out of hours doctors.
Dr Robert Stewart, clinical design director and Kent integration pioneer steering group chair.