NHS confirms integrated care systems to serve more than 20 million

• Jul 11, 2019

According to an article by NHS England, the North East and North Cumbria will become the country’s largest ICS, serving more than three million people alone.

South East London becomes the first ICS in the capital while Buckinghamshire, Oxfordshire and Berkshire West makes up the third new area where different health and care organisations work together to plan and join up services.

Each has shown that its partners all share a common vision to improve health and care, backed up by robust operational and financial plans, and proposals for collective leadership and accountability.

They follow in the footsteps of the 12 earliest integrated care systems announced in 2018, plus two devolved health systems in Greater Manchester and Surrey.

ICSs are already helping people to stay healthy and independent for longer, giving more care closer to where they live and work, and improving response times and performance in areas such as cancer and A&E.

Successes to date include:

• 100,000 more general practice appointments available for patients in Gloucestershire backed up by extra home visits from paramedics and physiotherapists, and medication advice from clinical pharmacists based in GPs’ surgeries
• Best practice care for people with atrial fibrillation is being expanded to every GP practice in West Yorkshire and Harrogate. This will prevent nearly 200 strokes to 2021, saving £2.5 million in costs that the NHS will reinvest elsewhere
• A single care record for each of Dorset’s 800,000 residents, allowing health and care professionals across the county to see the same information in real time. Joining up information in this way means patients no longer need to repeat their story to different teams and improves care because their full needs are better understood.

These changes have been made possible by different organisations – NHS hospitals, GPs, councils, care homes and others – joining forces to agree and plan for local people’s needs.

Speaking to health and local government leaders at the NHS Confederation’s conference NHS England chief executive Simon Stevens (on Wednesday June 19) is expected to say: “The Long-Term Plan showed how the NHS and its partners will improve care and help people live healthier day-to-day lives over the next decade.

“To meet these ambitions, every NHS organisation will need to intensify partnership working with others – including local councils and community organisations – for the good of those we serve.

“These areas are among those showing the real gains of collaboration: helping more people to stay well and avoid needless trips to hospital, while making it easier to get high-quality specialist care.

“We must keep a laser focus on making services as convenient as possible – everyone should feel like they are dealing with one system instead of having to repeat their story to a series of different organisations.”

Cllr Ian Hudspeth, leader of Oxfordshire County Council said: “The move to integrated care across the country gives us the opportunity to really make a different for our residents and communities.  Locally, I’m convinced that working together in partnership with the NHS we will deliver huge benefits to the health and care system and will improve the health and wellbeing of Oxfordshire’s residents.”

The systems will be built on a foundation of primary and community care, with primary care networks bringing together different professional teams – GPs, pharmacists, mental health and others – to invest a growing share of funding to do more in community settings.

They will also lead the way in developing a shared, in-depth understanding of residents’ full health needs, using ‘population health management’ technology to identify those at greatest risk of different ailments and supporting them as early as possible.

Buckinghamshire, Oxfordshire and Berkshire West

• As further developing strong relationships in each of the three places, the Buckinghamshire, Oxfordshire and Berkshire West integrated care system is working together at scale to reduce duplication through system-based procurement and distribution and to improve access to services such as elective care for their 1.8m residents
• Adopting a ‘do once and share’ approach across the system is helping to minimise waste, reduce unwarranted variation in care and outcomes for local communities
• Building up from the 45 Primary Care Networks (PCNs) which form the core building blocks of the system, the three places work in close partnership with local authorities to improve the health and wellbeing of local residents.  For example, in Berkshire West, integrated paramedic home visiting gives residents rapid, one-stop care that takes account of their whole needs. Thanks to closer collaboration between primary care, social care and voluntary services, more are now treated at home. This has improved care quality, use of resources and staff experience, reduced deterioration and length of stay, and allowed the system to manage demand more evenly throughout the day. In the first seven months, 96 attendances were avoided, and 75 sessions of GP time saved
• In Oxfordshire, integrated working has enabled partners to establish a jointly commissioned outcomes-based contract for mental health that will improve access, quality and support locally.
• The over 75s community nursing project in Buckinghamshire helps support older patients before they hit a crisis to prevent unnecessary hospital admissions and maintain their independence. The service includes a trusted first point of contact to reassure elderly people and link with other services, specialist nurses and community link worker who can help navigate other services including health, social and voluntary care.  To date, the scheme has increased referrals to memory clinic services, reduced by 54 per cent A&E attendances by people over the age of 75 and helped reduce the average length of hospital stay of 9.2 days (national average is 10 days).

North East and North Cumbria

• The North East and North Cumbria system is a strong performing system, with a long history of collaboration that builds on the foundations established in North Cumbria, which has been an ICS since 2017
• Covering a population of over 3.15m, the NHS in the North East and North Cumbria will be working together with 14 local authorities, the voluntary and community sector and wider partners to tackle the area’s biggest killers, which include cardiovascular disease, respiratory disease and cancer. For example, regional investment of £2million will help 250,000 cancer patients get speedier diagnosis and treatment through the new shared digital pathology service.
• Hospital-based Public Health experts will help make all hospitals smoke-free, provide advice and support to improve the health and wellbeing of patients and staff, and train frontline staff to help patients quit smoking for good
• To improve access to local GP-led services, the system will build on the existing 71 primary care networks to ensure 100% coverage by the end of the month. This will give patients access to clinical pharmacists who help manage medicines; local link workers offering advice and signposting to activities such as walking groups or volunteering opportunities; physiotherapist and community paramedics
• Around £22m is being invested in the Great North Care Record to give staff the information they need to care for patients whether they go to Northumbria or North Tees, making sure patients don’t have to repeat their story
• Improved tech and information will also help GPs and other frontline staff identify patients who are at risk of heart disease, COPD or diabetes, meaning earlier, faster and appropriate treatment for patients
• A north east and north Cumbria wide campaign – Find Your Place – encourages trainee doctors to choose the region for training and employment, and has so far seen a 10.5% increase in fill rates across the area.

South East London

• South east London’s health and social care system comprises five provider trusts, six CCGs and six local authorities together serving a diverse population of circa two million
• All organisations, together with wider voluntary partners and local communities, are working together to improve access, performance and quality of care.  For example, in cancer services, the south east London Cancer Alliance has introduced a Rapid Access Diagnostic Clinic at Guy’s and St Thomas
• The clinic is for patients that go to their GP with vague but worrying ‘red flag’ symptoms and allows them to be booked in to see a consultant to have many diagnostic tests on the same day
• This model has now been rolled out across the six south east London CCGs and to Queen Marys Hospital in Sidcup. Over 1,000 patients have been reviewed – 7% of whom were diagnosed with cancer, and 40% of those at an early stage
• The One Bromley partnership has improved support for patients with complex and long-term conditions who are identified by their GP, assessed by a community matron and have a care plan put in place to help them stay well.  A team which includes GPs, community matrons, specialist hospital consultants, mental health services, social care and the third sector have improved the quality of care for over 3,400 local patients. It has also relieved pressure on the local emergency care system, reducing A&E attendances and admissions by 34% for this cohort in the first 6 months
• The South London Mental Health and Community Partnership (SLP) – a collaboration of mental health providers (Oxleas FT, South London and Maudsley FT, and South west London and St Georges NHS trust) – work together to improve care, reduce variation and make best use of resources and new technology
• For children and young people’s acute mental health services, collaboration between providers has enabled care to be delivered closer to home – with a 75% reduction in out of area placements
• A shared care record in south east London now spreads to over 1.7 million patient records that have been viewed over 5.3 million times by clinicians. The record gives clinicians access to a single view of a patient’s data that includes diagnostic reports, long term conditions and diagnoses, medications, procedures, treatment plans and discharge summaries.  As a result, doctors can make faster decisions and have become less dependent on work arounds such as calling colleagues at other hospital to access important clinical information.