The Whole System Integrated Care (WSIC) event was designed to bring key stakeholders together to find new ways to deliver care.
Two-day WSIC simulation event: 28th October and 5th November 2014
Context is the development of Whole Systems Integrated Care in Hounslow and North West London. This involves delivering integrated care.
WSIC Simulation showed that the Out of Hospital model (delivering care in the community rather than in hospitals) holds good.
Findings support the direction of travel and balances Out of Hospital care with hospital strategic plans implementation.
- Purpose was to develop and test our approach to developing a model of integrated care for Hounslow
- Over 90 people attended the two full-day simulation workshops
- Run by Imperial College Health Partners; hosted at the Sequential Simulation Suite at the University of Buckinghamshire, High Wycombe
- Each day was structured around three real-life scenarios covering areas of general practice, adult social care and community health.
- The workshops were designed as a practical approach to engaging front-line staff in visualising how the current system works (on day one) and (on day two) to co-design how a new system could look and their part in it.
- Allowed us to explore if we could develop a different conceptual approach (‘step-change’) to developing a Hounslow-specific model of care. We are on the right track with our four step model in NWL
- Helped us to test the robustness of existing arrangements and share our thinking around detailed implementation of the proposed new Model of Care
- Allowed us to test certain elements of our proposed model of care without having to do it for real first (eg, more clarity needed on the role of care coordination, thinking through the practicalities of implementing MDTs)
- Brought together and got buy-in from front-line professionals delivering care across the Hounslow health and social care economy as well as third sector organisations, patient, and service users and carers representatives
- A lot of energy and enthusiasm for positive change
WSIC Summary of challenges & potential solutions
The issues addressed broadly:
- 1 Fragmentation and complexity
- 2 Lack of continuity of care
- 3 Not making the best use of existing resources, people or services
- 4 Lack of communication between services and of sharing of knowledge
- 5 Patients / service users / carers should be better supported to self-care, monitor & manage their own condition(s)
1 Fragmentation & complexity
2 Lack of continuity of care
Peoples’ needs are compartmentalised or medicalised – no view of the needs of a person as a whole.
No one person takes responsibility for the patient / service user across different services. Even within one service different people can see one person, even in the same settings (eg GPs, hospital appointments etc)
Lack of shared information (eg care plans) precludes effective joint working across organisations; (IT and IG constraints compound this)
Make sure everyone has a care plan who needs one and – critical – engage the patient / service user / carer in its creation / maintenance to get ‘buy-in’
Implement an electronic real-time shared joint care plan – the focus should be on personalised, outcome-orientated care and giving a person options
Create a care coordination role whose purpose is to consider needs of a person as a whole and to ensure that the care plan effects this
Institute multi-disciplinary teams to review care plans for complex patients when needed
Longer assessments with GP (eg 30 minutes) with further support (eg 40 minutes) from eg practice nurse at same appointment
3 Not making the best use of existing resources, people or services
4 Lack of communication between services and of sharing of knowledge
Organisations simply do not share information effectively – only the patient or carer has the ‘full picture’ of their care.
Staff in health and social care often don’t know what other colleagues do let alone what other services exist
Lack of ‘signposting’ of patients / services users to other services that would help them
Develop joint shared care plans and give the patient / service user / carer the most recent hard copy they keep with them for all appointments etc
Organise cross-organisational training around aspects of integrated care (eg people skills, services offered); mix the disciplines. Include paid carers and voluntary organisations / services. Mix learning styles
Share information across organisations: central directory resource, leaflets
5 Patients should be better supported to self-care, monitor & manage their own condition(s)
Children who see domestic abuse are victims too
The NHS waiting list crisis
GP Recruitment crisis 2017
How to do an NHS patient survey
Behaviour change in primary care
NHS Innovation labs
Game theory in healthcare.
Hiyos Helpers – NHS volunteering