Hounslow Integrated Care Partnership Update for Overview and Scrutiny Committee Martin Waddington
Hounslow Health and Care Partnership: Who are we? Hounslow Health and Care Partnership is comprised of local health, care and voluntary sector organisations are committed to working much more closely together to try to solve the problems that we share. We also need the insight and experience of patients, residents and carers to guide us and help to make these changes a reality. We believe that by all working together we can improve local services and make them fit for the future.
Our Vision, Values and Aims Our Vision “To be a place that provides continuity of care and support, leading to empowerment for all. This will mean better health and wellbeing for the people of Hounslow. Services will be more joined up, with a strong local focus; care will be delivered as close to people’s own home as possible.” The Triple Aim
What are our priorities? Our priority in Hounslow is to make our borough the best place it can be and we are ambitious about what we can achieve. However, in order to get started, we have been focusing on four areas: 1. Managing the demand for services like urgent care in a different way and stop the growth of unplanned hospital admissions. 2. Improve the assessment and care planning of our residents who regularly visit multiple services without having their problem solved. 3. Reducing duplication and sharing information more sensibly among all of the many organisations who visit our residents in their homes. 4. Help residents who are at a rising risk of developing poor health; at risk of falling; and at greater risk of having a stroke, or developing heart disease. 4
System Benefits The priority areas listed previously are being developed and delivered through work groups (Urgent Care, Home, High Intensity Users, Deterioration). The work groups are attended by all partners, including the voluntary sector and clinicians. The groups are the vehicles/starting point for working through the key issues, and developing solutions to deliver the wider ICP system benefits: • services of consistent quality and impact that are equally accessible by all residents across the borough; • comprehensive services that address peoples’ broadest health and wellbeing needs in a joined-up way; • effective coordination of the system overall (with clear accountability and responsibility for making decisions about people’s care) and frontline care (with clear access points and navigable care pathways); • providers working together in the best interests of Hounslow residents and the system overall; • making best use of the resources (workforce, estates, equipment and technology) within the system; • demonstrable financial sustainability based on providing the right care in the right setting at the right time. 5
Key Milestones to April 2020 � A Memorandum of Understanding was signed off by senior members of all relevant organisations to make sure that closer working across Hounslow becomes a reality. � From September 2019, all of the organisations involved will receive support to strengthen their working relationships. A joint staff engagement programme aimed at all staff will be taking place this year. � We have made a commitment to change the way we work , for example by changing the way we run meetings to free up staff from the various organisations to work together. � As well as the joint work in the four areas listed previously, a group of data analysts have come together to analyse health behaviours and investigate how much a service may cost to run in the future. This will help us to understand what will happen if we do not make a change and where we need to focus our energy. � We have started a process to agree how we will organise and monitor this new way of working. By April 2020, an alliance agreement will be put in place. An alliance contract by April 2023, will formalise partnership working between all Hounslow health and care partners. � The first wave of changes related to Urgent Care and High Intensity Users cohort will be implemented. 6
Communicating and Engaging with Residents Hounslow staff and residents need to fully understand what these changes might mean for them and how they can get involved. We learn the most from people who have lived experience and our goal is to bring together the expertise of our staff, clinicians, residents and carers and help them to get involved in developing these solutions. • A Hounslow-wide communications and engagement working group continues to co-ordinate, target and join up communications across all system partners with the aim of using relevant communication tools and messages to keep our residents, staff and stakeholders informed and engaged in the developing plans for ICP. • The group is particularly focused on developing communications that offer clarity on what the Integrated Care Partnership will achieve whilst avoiding duplication and confusing messaging. It consists of representatives from all partners, as well as Healthwatch and the voluntary sector. The GP Consortium is also involved in the work. 7
Example for residents –High Intensity Users What is the problem? • High Intensity Users (HIUs) of health and care services are a relatively small cohort of patients who account for a disproportionately large proportion of service use. Whilst potentially amenable to intervention, HIUs are often a poorly-defined, heterogeneous group with complex, and sometimes non-medical, needs. • The health and/or care needs with which they present, is not being satisfied by the services or organisations they make contact with. This results in them repeatedly returning with no clear resolution. • HIU patients are often of low socioeconomic status and have multiple medical, mental health- related and social issues. What will change? • In Hounslow, a group of clinicians and managers has been established to review and develop a new model of care to address gaps in service and improve patient care for HIU. The group consists of all health and care organisations across Hounslow who are focused on finding a consistent and efficient way of addressing HIU cohort’s needs. • By reducing activity in a hospital setting, for example, residents could be supported in a way that better meets their needs, such as social prescribing. We are working on this with the local Primary Care Network Clinical Director and identifying people with lived experience to help shape the model of care. 8
Example for residents – Home What is the problem? • For many years now, service users and carers have told us that we as professionals don’t communicate with one another when we provide care and support in peoples homes. Often the support is not joined up, repetitive and we miss opportunities to intervene earlier and provide more holistic support. What will change? • By working together with teams across all organisations we have started a dialogue about integration with frontline staff and are involving them in re-shaping how we approach coordinated, holistic care and support in a single space – the Home. This means professionals in multiple organisations communicating with each other about a person’s need to improve the their outcomes. Data Pilots requests • Home ‘register’: Hestia • Health data to be analysed Integrated Support Service, against social care and HRCH, Bristol Court housing • Coordinate My Care – Bristol Court October 2019 October – November 2019 9
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