“Our aim is to use the next several years to make the biggest national move to integrated care of any major western country.”

— NHS England update on the Five Year Forward View, published in March 2017.

In line with the Triple aim of better health, better care and better value, systems need to provide holistic person-centred care.  They need to empower people to remain independent and well for as long as possible and, when they need care, ensure it is easy to access and well coordinated across every care setting.

Current working practices demonstrate that achieving this is hampered by operational pressures and constraints on funding, which requires more than simply working harder. It requires developing new ways of working and new models of care to meet the rising demand and enable care to be delivered well in the home, the community and hospital, to best meet individual needs.  In parallel there needs to be a focus on preventing ill health by working with local authorities and other agencies to promote health and wellbeing, tackle risk factors and reduce health inequalities.

Redesigning how care is delivered

Integrated care happens when organisations work together to meet the needs of their local population. Integrated Care Systems (ICS) are a key vehicle for improving outcomes, transforming care and optimising the use of resources across local systems. Their success over the coming years will be crucial to the future of NHS and social care as we know it.

In delivering these changes system leaders are challenged to both focus on current performance and to embed new organisational structures and ways of working.  This necessitates developing new partnerships and new contractual agreements; new services and infrastructure to address logistics, financial and workforce challenges; and new sources of investment to deliver the necessary change.

SCW can work at multiple levels in the system, supporting leaders to plan, manage and evaluate change, developing person-centred care models, driving digital integration and piloting innovative approaches to system-wide ways of working. We have been involved with new care models, such as primary and acute care systems (PACS) and multispecialty community providers (MCPs), and have hands on knowledge of some of the innovations currently being implemented.

Effective leadership

Achieving the benefits of integrated care requires strong system leadership, professional commitment, and good management. It will be important for local leaders to invest time and effort in building trust and developing collaborative relationships with others in the local system. This really helps to overcome competitive behaviours that in the past have created barriers to partnership working and to deliver the level of change that is required.

SCWs experienced team have worked with system leaders to develop the behaviours and processes that will maintain the performance of current services whilst driving forwards integration across service and organisational boundaries.

Engaging with stakeholders

Integrating services between primary, acute, mental health and social care is a fundamental part of creating new ways of working. Engaging with a wide range of stakeholders, clinicians, care professionals, service users and citizens is important. We can work with you to understand their motivations, needs and concerns and to involve them in developing new care models. Ensuring the key stakeholders are part of the development process provides transparency and will enable you to deliver a more sustainable, community owned and a truly localised solution.

Integrating care and improving population health involves looking at best practice and using it to develop innovative ways to improve care pathways. Learning from what is already working well, we can help you develop and articulate your future vision for integrating care and improving your population’s health, working with you and your stakeholders to identify and overcome any barriers to achieving this vision.

We can also work with you to exploit the power of community assets to generate social connections and improve resilience and support. Community organisations such as community choirs, walking football, or riding for the disabled, all demonstrate the power of the voluntary sector to support individuals to experience fulfilling lives.

Promoting health and wellbeing is a critical component of a sustainable care system and we know that when people are informed and truly part of shared-care decision making they can help to create innovative and less invasive solutions to their health and social care needs.  Using a combination of pioneering technologies and development and promotion of self-care programmes supported by our innovative behaviour change and social marketing service, we can enable people to live with greater independence, confidence and safety, reducing the need for unplanned care.

Creating insight and understanding

To enable everyone to easily share information and gain insight a system wide strategy is needed.  Delivering integrated care services needs a “whole person” view in order to provide seamless and effective services. This starts with understanding need, activity and cost across the population through to monitoring service delivery using a wide range of tools and methodologies based on the available data. Using our Population Health Management (PHM) tools, SCW analytics teams provide a whole-system view to help target resources effectively on appropriate patient cohorts. Our team of business intelligence experts can work with you to understand how you are operating currently, where you would like to be in the future and how you will get there.

Sharing information

Local Health and Care Records (LHACR) are also a crucial component supporting new developments in health and care delivery, with interoperability vital to the success of integrated working across a system. We can work with you to develop your local digital strategy in a way that is user friendly and helps give useful information quickly and easily to support all parts of the system in playing their role in delivering high quality, effective and efficient care. We provide strategic and technical expertise to deliver end-to-end support that covers engagement, strategy, infrastructure, implementation and continuous improvement, and have used this to combine health records for several major health and care systems.

Buying the right care for your population

Once you have developed a vision for your new model of care, making this sustainable will be important. To help with this we work with you to establish governance frameworks to develop and manage commercial and contractual relationships with other members of your system. This can include moving to managing funding for a defined population by taking responsibility for a system ‘control total’ and planning for outcomes-based contracts in the longer term. Complementing this is the introduction of at-scale Personal Health Budgets and Integrated Personalised Commissioning allowing for empowered patients who are able to purchase innovative solutions to their health and social care needs.

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