Pioneering Islington CCG is leading the way in integration and reaping the rewards
Islington Clinical Commissioning Group (CCG) is made up of 36 GP practices and is responsible for commissioning more than £300 million of healthcare services for the people of Islington.
Islington is a wave one integration pioneer. This recognises our innovative approach to partnership working and system leadership where we have demonstrated a commitment to use our learning to inform whole-system-thinking and collaborative working to accelerate service transformation. Our work is focused on delivery of value, sustainability and by local voice, through embedded systems of co-production with users and staff.
The Islington patient narrative was made real in 2012, during the development of our patient and public participation strategy; mirroring the themes in ‘I statements’ (a person centred statement developed to explain what they want to see from health and care. For example: “I want to be treated with dignity and respect”) developed by the National Voices. The NHS Commissioning Board now NHS England commissioned National Voices, the national coalition of health and social care charities and its members, to develop a narrative for integrated care from the perspective of the patient and service user. It is the fulcrum of our single compelling vision for the integration of health and care.
Our aim is to take a universal approach that encompasses children and adults, with a strong focus on prevention.
Work to date has focussed on the development of the key enablers to deliver a meaningful person-centred offer.
We are building a systematic approach to support the delivery of person-centred care with a strong focus on supporting self-care as well as undertaking ground-breaking work to deliver an integrated digital person-held record, making the individual or their carer the holder of key information and of consent to access it.
We have worked with stakeholders and users to define the key person-centred outcomes to drive a value-based commissioning approach for clinical pathways, including diabetes. This is with a view to the implementation of an innovative contract form that supports integrated practice units. To measure our success we have used a logic model that aligns elements of our integration programme with those identified in the ‘I statements’; driving the programme towards a set of carefully chosen metrics.
Since April 2014 we have developed a community education provider network (CEPN); a partnership across health, social care and the voluntary sector now mandated to inform and implement workforce development and planning across Islington. With a focus on the development of multi-disciplinary collaborative educational processes this work has been ‘bottom-up’, and modelled through ‘listening’ events and a methodology of integrated workforce assessment modelling. It identified the key knowledge, skills and behaviours required to deliver a meaningful person-centred approach.
Within our ambition is a strong focus on the nurture of a local workforce, through the growth of career progression for unqualified caring staff, trying to get local people with a lack of education into work and also drawing workforce from the local population into careers in health and care; growing opportunities through an apprentice programme and the development of a ‘super-hub’ to champion programmes for community nursing, including a test of concept (pilot) development of blended role fellowships for nurses and GPs across the acute-community interface.
Our integrated care team is driven by a talented and committed commissioning workforce led by GP clinical leaders with a solid understanding of the local community’s health needs and a huge amount of energy and passion. We understand how our shared vision must be owned and understood across our partnership. The vehicle of the CEPN is important for this, as through multi-disciplinary education we can build relationships, mutual trust and parity of esteem.
Engagement with staff has been an important enabler in service redesign; the approach of test and learn continuous quality improvement cycles, has been a powerful force in exposing and developing our distributed leaders, maturing ownership of our local vision and accelerating the implementation of change.
It has been important to communicate our shared vision and to develop a portfolio of tools to do this. We have found the use of impact stories (the name given to local “case studies” that document the experience of real people/situations) to be especially useful because showing how things are really working/making a difference helps justify why would we do things differently. Working with the Young Foundation to co-produce a film, We Care Together – Maggie and Rose’s story, with staff and service users, is an example of key messages being delivered about workforce development, the value of integrated working and the importance of community asset. We have also designed an interactive web portal to support continuous professional development in the delivery of integrated care.
Integrated community ageing team
The integrated community ageing team (ICAT) brings consultant geriatric expertise out of hospitals and into the community. The team comprises geriatricians across Whittington Health and UCLH, an innovative specialist-generalist role (GPwSI geriatrics), pharmacists, nurses and therapists. Starting in care homes, the team is now expanding to the community, delivering comprehensive geriatric assessments, an evidence-based intervention recommended by the British Geriatrics Society (BGS) as the gold standard for the management frail older people.
Since February 2014 the service has had a 30% decrease on reducing the number of people attending A&E from care homes. However, we are working with the Nuffield Trust to develop robust methods of evaluation for 2015/16.
HealthWatch Islington has independently evaluated the service, as part of their remit in ensuring that services are meeting the needs of local people.
Integrated health and care teams
Our integrated health and care teams are being developed through a real time, test-and-learn approach. This pilot works out of eight practices in Islington and brings together GPs, nurses, social workers, mental health professionals, locality navigators, acute colleagues and pharmacists. These groups are tasked with finding new ways of managing people with complex needs. The finalised model will be rolled out across Islington from October 2015.
Dominic Roberts, Islington CCG clinical director who is also a GP in Hackney, had an opportunity to observe a test and learn meeting recently. He reflects on his experience: “I enjoyed observing an innovative and exciting MDT and was impressed with the level of effective patient discussion that occurred in such short time slots (five-seven minutes). There was a strong sense of teamwork in a relaxed atmosphere where team members had evidently built up rapport over time. I witnessed the benefit of a much wider MDT presence compared to traditional MDT meetings. The benefit of GP practice collaboration was demonstrated in terms of expertise sharing, networking and pooling of resources to distribute time and costs of the MDT team. The themes and learning about complex patient management can be cascaded to the wider community team so that the benefits spread beyond patients who are discussed, particularly awareness of community resources. This model has great potential for better patient care in the community.”
In conclusion, we believe in the need to work with patients and carers in a different way; co-production both at strategic and personal level. The delivery of meaningful person centred care takes time and skill and needs to be systematically applied across all providers as an aligned way to ‘do business’. This can in turn increase productivity and enhance patient experience.
We will continue to actively engage and grow our system leaders, through experiential work so that our shared vision is locally owned and informed.
We continuously return to our local ‘I statements’ to ground our thinking and we continue to listen and utilise feedback.
Jo Sauvage, vice chair, Islington CCG.
1. National Voices. http://www.nationalvoices.org.uk/ (accessed 10 June 2015).
2. The Young Foundation and Islington CCG. We Care Together – Maggie and Rose’s story. 2014. https://www.youtube.com/watch?v=3aUXW3FBNlc&feature=youtu.be (accessed 10 June 2015).
3. British Geriatrics Society. Comprehensive geriatric assessment. 2014. http://www.bgs.org.uk/index.php/cga-managing (accessed 07/06/205).
4. HealthWatch Islington. Experiences of Integrated Care Ageing. 2015. Team. http://www.healthwatchislington.co.uk/sites/default/files/the_integrated_care_ageing_team_service_2015.pdf (accessed 07/06/15).