What’s it all about?

People are living longer, often managing one or more long-term conditions such as diabetes or respiratory conditions. These patients often receive care (both health and social care) from a range of sources.

This care is generally good but it is often un-coordinated, leading to fragmentation, duplication and avoidable admissions to hospital. The expiry of the current contracts for community services presents an opportunity to rethink how community services are managed and delivered.

The case for change…

People with long-term conditions may have a whole range of health and social care professionals caring for them, as well as their families, carers and the voluntary sector. But these people often do not work as a team. They work for different organisations, with different working practices and may not communicate with each other well.

For patients, this can mean repeating details several times and often confusion about who is co-ordinating care – and who is ultimately responsible.

Lack of co-ordination means patients can lack confidence that their conditions are being managed properly - patients aren't sure who to call when they are worried or their condition exacerbates. All too often, they end up being admitted into hospital via A&E. Each one of these unplanned admissions is an expensive failure of the system.

Integrated care is about doing the right things, in the right places, at the right cost, at the right time.

Locality teams

Eight locality teams are being established across Oldham, each serving a population of around 30,000. They will deliver care in a co-ordinated way around the patient by bringing together the services they need to access across health and social care.

Local GPs will lead these teams, made up of staff from a number of organisations across local care, and supported by four locality planning teams.

Patients meeting the criteria for this approach will be identified by ‘risk stratification’ – a process of working out who has the greatest need.

Success indicators

We will know this approach is working if we see evidence of:

•  A joined up patient experience

•  Planned, timely care resulting in fewer presentations at A&E and unplanned hospital admissions

•  Reduced repetition and duplication

•  Increased continuity of care

•  A personalised, tailored service wherever possible

•  Shared decision making

Making it happen

All the service providers involved are on board for this approach.

We have undertaken patient and carer engagement resulting in a consensus that this is a sensible way forward. In fact the main challenge was to ask why this wasn’t happening already! Details of the feedback received and further opportunities for involvement can be found here.

Roll out of this approach is imminent with the current contracted providers. Meanwhile, invitations to tender for provision community services will go out in August 2013 in 6 ‘lots’. These service specifications reflect a more integrated approach. Details can be found here.