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Our plans

Integrating health and social care services

Integrated care is about joining up the range of different health and social care services patients may receive to ensure they experience it as one seamless service, with their needs placed at the centre.

People with long term conditions require regular support and treatment and we want services to be easier to access, and to help people to better manage their conditions themselves, so they are less likely to require emergency care.

Central London CCG therefore wants to create a health and social care system that is truly seamless so that people receive the right care and support at the right time, in the right place. Bringing together all the different parts of the health and social care system will provide better communication and sharing of relevant information to reduce duplication and confusion for individuals, carers and staff. This will mean one set of goals agreed by the individual, supported by one team with one approach.

This is known as 'whole systems integrated care'. Find out more about joined up care here.

Integrated Care

 

This vision will mean a new way of delivering care. A model of care that starts with people’s needs, whether social, physical or mental, and makes sure that the whole system’s resources are directed to those needs. This model will mean self-empowerment, use of community capital, networks of GPs, networks of providers and the system enablers such as the right information, the right workforce, and the right estate to support it: a whole system of care. 

We have already begun some of the practical steps necessary to deliver this:

  • We have created nine sub-locality units. These are known as integrated care ‘villages’.  These villages pool the professional knowledge of GPs, community nursing, social services and environmental housing to create a more seamless, efficient care system with each step of the process properly joined up. A care navigator is aligned to each village to oversee community referrals and to help support patients upon discharge from hospital.

  • We created a children's general practice Hub. The Hub puts the GP surgery at the centre of child health, bringing together and integrating professionals and access to community support. The hub creates better outcomes for children, enhances paediatric skills and competence across the system, reduces unscheduled care, inpatient admissions and paediatric referrals, and enables effective and easier access to specialist paediatric skills.

  • We are working with Westminster City Council on the delivery of the Better Care Fund to help integrate services.
  • Along with West London and Hammersmith and Fulham CCGs, Westminster City Council, the Royal Borough of Kensington and Chelsea and the London Borough of Hammersmith and Fulham, we are delivering a triborough integrated community independence service (CIS). The service will be provided by health and social care services working together, seven days a week, to provide rapid response services to help patients avoid hospital admissions; in-reach services to bring people home sooner from hospital admissions, and rehabilitation and reablement services to help people return to independent living as soon as possible. 
  • We are increasing the investment in neuro-rehabilitation community support and bed based intermediate care in the community to support recovery and return to independence.
  • We are working with the public health team to develop supportive and resilient neighbourhoods and communities across tri-borough, reducing demand for health and social care services and improving individual outcomes.


Find out more

To find out more about how the eight CCGs are working together to deliver integrated care in North West London, visit the whole systems integrated care website.