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Whole Systems Integrated Care. Central London / Westminster. Whole Systems Event – Capture of discussions. 9 nd April 2014. Who attended. *No representation from the Imperial or Chelsea and Westminster Hospital.

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Whole systems integrated care

Whole Systems Integrated Care

Central London / Westminster

Whole Systems Event – Capture of discussions

9nd April 2014

Who attended
Who attended

*No representation from the Imperial or Chelsea and Westminster Hospital

Whole systems integrated care

Participants were asked to think about the following three questions after watching ‘Sam's Story’

  • Social isolation

  • Access to information

  • People falling through the net

  • Communication between the hospital and the GP

  • Lack of support when patients return home from hospital

  • Inter service boundaries

  • No coordination

  • Lack of good out of hours care

  • Financing of home care

  • Services are not rapid and responsive to me as a patient

  • Lack of dignity and respect for patients as individuals

  • Confidentiality – where sharing would support patients it should be made possible

  • Patients do not have enough control of their own destiny

  • Do not know / understand what services are out there and how to access them, especially within the voluntary sector

  • The lack of one team responsible and accountable for delivering my care plan

  • Many services the GP holds the ring on who is referred

  • Lack of support for carers

  • Turnover of staff

  • Lack of honestly and openness

  • Services / people need to do what they say they will do, when they say they will do it

  • Old attitudes, territory protection

  • To understand how the system works

  • A longer appointment with GP to discuss my complex health needs

  • Access to specialist professionals who understand my condition

  • I want to be able to plan my care

  • I want one person coordinating my care who understands my needs and can connect me with the right people

  • When I go into hospital I want to go home and do not want to go back into hospital unless my condition

  • I want to understand what peoples roles are and what support is available to me

  • I want staff to be consistent and give me the same advice regardless of who it is I am talking too

  • I want to know what free services can help me

  • I do not want my hospital appointments or operations to be cancelled as this makes me anxious

  • I want access to interpreter’s

  • I want to be able to view my record / care plan

  • I want a care plan that everybody follows

  • I want to be involved in planning and options about the care that I receive

  • I want to access services at a time that is convenient to me

  • I want my care to be right for me, not people who are like me

  • I want less bureaucracy, and less forms to fill in, I just want help with my care

  • I want professionals to explain to me what is happening

  • Acknowledge the role and expertise of carers, and their ability to make decisions

  • Trust patients and carers to know what they need and the best way to get it

  • Prevent peoples health from detraining

  • Ensure all patients with complex needs have a care plan

  • Increase confidence in information sharing arrangements

  • Being able to talk to somebody when patients feel they need too

  • Services that are personalised to ME

  • Personal decision making on what services are accessed and when they are accessed

  • Everybody should be able to plan their care regardless of funding and eligibility

  • I want one number that I can ring when I need help

  • End weekend delays, information readily available all the time




  • What stops people from achieving these goals today?

  • Sam’s goal was to be able to live independently at home…what goals do you have for your wellbeing?

  • What common goals should Central London CCG / Westminster support everybody to achieve?


What could whole systems integrated care look like in central london

Home based and residential questions after watching ‘Sam's Story

What could Whole Systems Integrated Care look like in Central London?

Detail based on discussions at CLCCG’s Whole Systems Event on 8th April 2014

  • Text

  • Hospital


  • GP to remain responsible even when the patient is in hospital

  • Responsibility for admitted patients to coordinate discharge

  • Care plan constantly reviewed with detailing goals and wishes

  • Discharge planning with people from access the system, to include carers, family, care coordinator

Home based and residential care

  • 24 hour care

  • Care plan constantly reviewed with detailing goals and wishes

  • Respite care

  • Domiciliary care

  • Pharmacist input

  • Formal appointment of family member to care (this to be recognised by the professionals)

  • Home care help and choices of time to access this home care

  • Supported living units

  • Text

  • Rapid response in the community

  • Routine care in the community

  • Text

  • Home based and residential care

Routine Care in the Community

  • Single assessment by a nurse or Doctor

  • GP coordinator

  • Team coordinator

  • Flexible team to support changing patient needs

  • 24 hour care

  • More services in the community

  • One computer system with a good backup

  • Clinical care coordinator

  • Foot care

  • Minor Surgery

  • Phlebotomy

  • Inter team referral for specialist opinion

  • Care plan constantly reviewed with detailing goals and wishes

  • Service support that is flexible based on needs and changing needs

  • Good access to GPs

  • Use of pharmacists in the community

  • Access to equipment such as wheelchairs, and handles

  • Single record across H&SC

  • Variety of times and appointments to suit different needs

  • GP to plan support in advance of patients going into hospital

  • Establish community wards for managing long term conditions and predictable hospital admissions

  • Structured care plan based on wishes of the patients – not based on what is on offer

  • Longer GP appointments

  • Flexible short term input when people with fluctuating needs require it

  • Local diagnostic units which stop patients having to go to hospital

  • Co-located multidisciplinary teams located in the community which include social care

  • Empowerment and self care

Rapid response in the community

  • Better access to OOH services

  • Care plan constantly reviewed with detailing goals and wishes

  • Respite Care

  • Access to a rapid service that is an alternative to 999

  • Alert system for people involved in an individual persons care to alert to crisis or hospital admission

  • Access to GPs / nurses in a crisis situation

  • Integrated re-ablement and rehabilitation in the community

  • Rapid responsible available to all (mobile doctors)

Empowerment and self care

  • Befriending

  • Information advice in suitable formats

  • Housing services

  • Education for self-management

  • Signposting to voluntary sector services

  • Wider voluntary support network

  • Integrated care plan written by myself and my career constantly reviewed includes my personal goals and wishes

  • Drivers / volunteers to bring patients to services

  • Telehealth

  • Education on medicines

  • Some services geared around improving mental wellbeing

  • Advice on benefits and welfare

  • Advice on exercise and healthy living in one place

  • Personal budget for those who would benefit