A practical way to join up care and focus on health for all

At Imperial College Healthcare NHS Trust’s 2016 annual general meeting (AGM) on 14 September, integrated care programme director Anna Bokobza set out a vision for a radically different way of providing health care. Here, Anna explains how an ‘accountable care’ approach – where health providers come together to take responsibility for the quality and cost of care for a defined population within an agreed budget – could finally deliver genuinely patient-centred, integrated care for local people.

Around a third of patients currently in one of our inpatient beds could be better cared for in the community or at home. Many are frail, elderly people and others with complex, long-term physical and/or mental health conditions. They remain in hospital simply because the support and services they need to go home or to a residential care facility aren’t easily available at the right time.

We also know that there will continue to be big increases in the number of people with one or more long-term conditions, such as diabetes or arthritis – by around a third over the next five years – and dementia – a 40 per cent rise by 2021. Proactive care to help people stay as healthy and independent as possible and manage their own conditions will need to be very different to the reactive treatment we tend to provide now.

If we continue to provide care in the way that we do now, the gap between how much money will be required and what is likely to be available will become ever more unsustainable – it’s estimated the shortfall will be £1.3 billion in north west London by 2021.

We need to move to a system that:

  • helps people to be as healthy as possible
  • helps people who become unwell to get faster access to care that will get them back to health as quickly as possible
  • joins up care and services and makes it easier for individuals to get the right health and care support for them
  • encourages partnership working between health and care providers and the individuals they serve.

That’s why we’re working with partners to see how we can transform the way we offer care. In July 2016, building on work that began in late 2015, we were one of four organisations that formed the Hammersmith and Fulham Integrated Care Partnership. Our partners are Hammersmith and Fulham GP Federation, Chelsea and Westminster Hospital NHS Foundation Trust and West London Mental Health NHS Trust as well as a number of lay representatives. Together we bring nearly 19,000 staff, 31 GP practices and nearly £200 million of budget to provide for the 190,000 people living in Hammersmith and Fulham.

We want to design a practical ‘accountable care’ approach – collectively looking after the holistic care needs of local people and helping them to stay as healthy as possible, from the beginning to the end of life, rather than providing separate aspects of treatment when they are sick. While the NHS has been talking about developing integrated care for quite some time and, in places, making it happen, we haven’t managed to provide care for everyone, all the time, that meets individual needs.

We think an accountable care approach can make the difference because:

  • it puts the individual at the centre
  • it aligns incentives so everyone is pulling in the same direction 
  • success and funding reflect what is achieved for the individual, not how much is done to them
  • the needs of the whole population are important, not just those who are acutely unwell
  • it demands joined-up information and care planning.

The partnership is undertaking a couple of pilot projects to help develop our thinking about how our whole approach can be transformed and to make shorter and longer term improvements. In our ‘familiar faces’ pilot project, we identified 71 patients who had visited one of our A&E departments more than 10 times in 10 months. Nineteen of these patients gave special consent for senior clinicians from across all four organisations to review their cases together.

Clinicians were able to identify key themes which we can use to identify how the patients’ journeys could be improved. We now have a better understanding of the needs of this vulnerable group of patients, many of whom have complex mental and physical health conditions. We found that A&E attendance was often due to complications arising from complex health needs that could be managed more effectively if the whole care system was working in a more joined-up way.

This pilot is helping us move on with our longer term aim of building strong foundations for potentially forming or becoming part of a formal accountable care partnership. Our aim is to ensure this partnership is ready to work with commissioners to develop and deliver an accountable care approach for our community from 2018.  

The key to creating a successful, sustainable accountable care partnership is developing trusting professional relationships that will enable us to design the right care pathways for people in our community. That’s why we want to get patients, carers and local residents, as well as staff from across the health and care system, involved in designing the pathways we need. It is vital that we all work together to bring our aspirations to fruition. If you’re interested in helping us build the accountable care partnership for our community, email involvement@imperial.nhs.uk to get started.