Hounslow Integrated Care Partnership Roadmap Hounslow CCG 23 August 2019
Contents Item Slide 1 Vision and ambition for the partnership 4 2 Scope, composition and partner commitment 10 3 Model of care 18 4 Approach to population health management 20 5 Priority areas of focus 22 6 How this plan and areas of focus deliver NWL financial recovery 25 7 Key milestones in development 29 8 Governance arrangements 31 9 Key areas for development support 34 10 Appendix 1 36
About Hounslow A young and enterprising Dedicated borough health and care staff who stay in the borough High More residents employment living with complex rates health and care needs A steady increase Around 3,000 older in unplanned people experience hospital chronic loneliness admissions Hounslow has a number of shared High levels of challenges across partners smoking and • Varied and Fragmented Care Staff who are • Duplication of services obesity invested in • Misaligned incentives • Workforce gaps Hounslow Source: Hounslow Joint Strategic Needs Assessment, 2017 and Loneliness and Social Isolation • Financial pressures in the London Borough of Hounslow, 2017
Vision and Ambition for the Partnership 4
Hounslow Health and Care Partnership: Who are we? Hounslow Health and Care Partnership has come together to build on what already works well in Hounslow to address our shared challenges. We are working to deliver a future, financially sustainable care and support system that improves patient and citizen outcomes by embedding the principles of integration, prevention, proactivity and localism.
Our agreed approach to developing Integrated Care in Hounslow We have agreed our joint working We are actively developing a joint We agreed that relationship Our emerging joint approach to governance arrangements and approach to population health building across the system is resources needed to build an ICP the roadmap will set the key management. In July a cross- critical to successfully build an has already changed the way we milestones for further system BI and analyst group has ICP. We will be starting an in- approach performance meetings development of our joint working launched its work to support depth OD programme that will with our provider partners. framework including risk and working groups in shaping of the support us in strengthening Through this we have been able share arrangements, partnership care models. The group will system relationships and to release staff from both CCG agreements/MoUs etc. We have support the ICP development by integrated vision for joint working and partner organisations to be also started work on jointly providing a system view and from September involved in ICP work. developing commissioning evidence for future care models outcomes for ICP. Joint vision Capacity Shared Framework challenges to work We release the capacity within to deliver integration Our shared challenges though Our framework that We want to set out that that we can only resolve enable us to work new ways of working and we work together by working together flexibly to realise our behaviours that support because… ambitions is… are…. that We build on what we do well, release our staff to adopt integrated ways of working and support our residents to co-produce the changes 6
Our Vision, Values and Aims Our Vision “To be a place that provides continuity of care and support, leading to empowerment for all. This will mean better health and wellbeing for the people of Hounslow.” The Triple Aim
Responding to our Population: Communicating and Engaging Strengths Hounslow has strong foundations of developing the vision for Hounslow health and care system across partners and the public: Principles of Integrated Care are well embedded in the Hounslow Joint Health and Wellbeing Strategy • Third Principle: Ensure services are well coordinated within and between partners • Fourth Principle: Work in Partnership Futureproofing Health and Social Care in Hounslow co-produced and co-designed • Developed across partners and service users in 2017 provided the strategic intent for integrated care • Sets out the vision for 2022 Hounslow Health System Hounslow Outline Business Case for Integrated Care shared with CCG Governing Body and all partners • Outlined four priority areas for development; urgent care, high intensity users, home, preventing deterioration Primary Care Network Development 2022 Hounslow Health System: Futureproofing Health in Hounslow • The ‘working together’ partnership between HRCH and Hounslow GP consortium is supporting the establishment of primary care networks (PCNs) and primary care at scale. • Phase 1 has included provision of corporate back office support to lead on the joint recruitment of pharmacists and first contact physiotherapists (FCPs) roles as part of the network delivery teams to increase provision of allied care professionals in primary care, as indicated in the NHS long term plan. Public Event in March 2019 • Testing the four priority areas In the long term we will seek to develop our knowledge of the population's needs and behaviours to co-develop Self Care, align Preventative Care with wider health and wellbeing and seek to address the social determinants of health. 8
Changing our Mindset, Culture and Behaviours We recognise that we have more to do to further develop, refine and socialise our shared vision and demonstrate progress on a regular basis to staff and stakeholders. Our vision is underpinned by the work required to change our mindsets, culture and behaviours. Theme Actions for 2019/20 Strengthen our relationships We agreed that relationship building across the system is critical to successfully build an ICP. Our CEOs have stressed this as our primary focus and have endorsed a in-depth 6 month OD programme that will support us in strengthening system relationships and integrated vision for joint working from September. Refine our shared vision and The OD work will further develop and deepen the collaboration, relationships and practice in order to purpose and understand our build and strengthen the foundations for an integrated place based approach to agree • Shared vision and purpose across health and care leaders shared challenges • Clarity about the behaviours and values that will guide system leaders at all levels within the health and care system in Hounslow. Engage and communicate We will build on our communications strategy and work to date with the community and staff to demonstrate our progress. • Our Hounslow Comms and Engagement group (which includes comms and engagement leads from all partnering organisations) will shape the strategy for engaging and communicating about the ICP and the work we do to both staff and the public. • This will enable Hounslow staff and residents to understand what ICP means for them and how they can co-design and co-produce the care that ICP will be providing to our local population. Our approach is to a joint leadership and engagement programme targeted at all levels of staff; executive, middle management and frontline. • Utilising our strong partnership working with the VCS we will continue to develop our approach and emerging models of care jointly. 9
Scope, Composition and Partner Commitment 10
Scope, composition and partner commitment • This roadmap demonstrates our 18-36 month plan. It is not the endpoint. The focus of this iteration of the Hounslow Integrated Care Programme is to develop and deliver an integrated model of health and social care for patients and citizens who are current users of our local health and care system. • We recognise that the health and care system is evolving and is under financial stress. The solutions and scale of solution will be variable and it is critical that the partnership operates across the key building blocks of Neighbourhood (as defined by the Primary Care Networks); Place (defined as the Borough) and the System (defined as the North West London sector). Our key building block and primary area of focus is at the Place level. • We expect our local Place Based Integration to evolve far beyond the programme of work presented here and our aspiration is for place based public service integration in Hounslow with blended leadership and redefining the service user relationship with our population. SCOPE: • The Hounslow approach to designing solutions is to be resident-centred and co-produced. By building on existing quality improvement approaches embedded within some of our partners we will empower staff and clinicians to develop solutions that allow them to work to the ‘top of their licence.’ • Therefore, the scope is fluid, and the lines/services incorporated on the next page is indicative of the ambition of our Hounslow system leaders. If workstreams can demonstrate system benefits by including services outside scope, or that don’t obviously align wi th the scope, there will be opportunity to incorporate these (subject to agreed sign-off arrangements). • We recognise that some of the highly specialised services delivered across Hounslow will be identified and may be aligned or integrated with NWL or London-wide rather than within Hounslow ICP (e.g. forensic mental health etc). Scope of Current Integrated Care Programme 2019-2023: Evolution of Integrated Care Partnership and its agility between Neighbourhood, Place and System 2023 Onwards : Place Based Public Service Integration 11
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