Agenda item

The Integrated Care Network update was provided jointly by Mark Cheung and Dr Andrew Parson.

Dr Parson commenced by providing a brief summary of the key points of work undertaken to date, and by explaining that the aim of the Integrated Care Network (ICN) was to reduce hospital admissions. A summary was provided of the significant engagement that had already taken place with a variety of stakeholders. This was broken down into 4 main areas:

·  Involvement of GP Members

·  Involvement of GPs as providers

·  Involvement with other partners

·  Work in progress

The other partners involved included the GP Alliance, patients, Kings College Hospital, PRUH, Bromley Healthcare, Oxleas, St Christopher’s, and Bromley Third Sector Enterprise. The initial stages in the ICN process would commence with all health care professionals case finding and identifying individuals deemed as high risk, and providing their details to the MDT Liaison Coordinator (MDT is Multi-Disciplinary Team).

It was noted that the next step in the process would be for the MDT Liaison Coordinator to support GPs with updating EMIS—the GP information system. Verification would be provided by consulting the patient to see if they were happy to be put on the Proactive Care Pathway. 

Dr Parson informed the HWB that a number of GPs were already engaged in the process, and were involved in the mechanism of case finding deteriorating or difficult to manage patients. These details had been forwarded to the relevant MDT. The plan was to bring together a team around the patient to enhance patient care and experience. In most cases, initial holistic assessments would be undertaken by Community Matrons—this could be face to face or in a virtual environment. Information would be available to everyone involved to facilitate joint working. 

The next stage in the Proactive Care Pathway would be the formulation of an Integrated Care and Support Plan—this would be developed by the Community Matron in conjunction with the patient, and supported as required by the Care Navigator. After this, there would be an initial MDT meeting, where the Care Plan would be ratified, and the Clinical Lead would be assigned.

The Board heard that in terms of governance, a nominated GP Chair would Chair the MDT meetings to ensure that the patient’s needs were considered and actioned. A re-assessment would be undertaken when required, as would reviews of the Care and Support Plan. If the Integrated Care and Support Plan was updated, this would be shared with the patient and the most relevant person. Throughout the process, the patient’s main point of contact for Primary Care would be the Clinical Lead, and the main point of contact for all other issues would be the MDT Liaison Coordinator. Dr Parson highlighted the key role that Geriatricians would play in implementing the Care Plan for the elderly. It was anticipated that input would also be provided from the voluntary sector, and that social prescribing would also be used where appropriate.

The Board heard that the recruitment process for recruiting into key MDT roles was nearly complete. The new key roles were outlined as follows:

·  GP Chair

·  MDT Liaison Coordinator

·  Care Navigators

·  Interface Geriatrician

·  Mental Health Professional

·  Social Prescribing Administrator

The Board heard that it was planned to roll out the new MDT system in three locations simultaneously. The Chairman asked if there was going to be a communications plan. Dr Parson responded that initially there would be no noticeable difference to patients, and so a direct marketing initiative was not required.

Cllr Evans asked for clarification of the role of Social Care in the process. He asked if Social Care would be consulted and officers involved. Dr Parson responded that the support of Social Care was required, and that plans were being developed with Lorna Blackwood (LBB Head of Adult and Community Services). The LBB Director for Adult Social Services assured that the appropriate Social Care systems would be in place.

The Board were referred to page 11 of the ICN report, and were given a brief overview of the Frailty Pathways for Step Up and Step Down services. The idea was to try and limit the admission of the elderly to A&E and to acute medical units. The gatekeeper for beds in the Integrated Unit would be a geriatrician who would be working to agreed criteria, and monitored by governance groups. Further objectives were to link more urgent out patients to the MDT, and to avoid the stress of unsuccessful discharges.   

Cllr Carr expressed concern around the efficiency of other boroughs in discharging patients that had been treated in Bromley. Dr Parson replied that, it would be important to ensure that other boroughs were working efficiently. Work was being undertaken with Kings and Community GPs to ensure that the relevant protocols had been put in place. Cllr Carr was concerned that social care funding could be used to fund the acute sector, and was worried that the proposed model could result in Bromley having to pay for the inefficiency of other boroughs. It was noted in this regard that other boroughs would be liable for excess charges. Cllr Carr was uneasy that the current model did not seem to provide any real incentives for other CCGS to be efficient, and Cllr Colin Smith expressed similar concerns. 

Cllr Dunn referred to the section on the report regarding a level of frailty of 6-7 on the Rockwood Frailty scale, and asked what this was. Dr Parson explained that this was a frailty score that was not based on age, but was based on function. Cllr Ruth Bennett asked if spare capacity in step up facilities could be sold to other CCGs. Mr Cheung responded that this had not been looked into, but in theory the answer was yes, subject to capacity allowing. A charging mechanism would need to be evaluated. 

Cllr Colin Smith expressed concern around the potential waiting time for those awaiting transfers late at night, or in the early hours of the morning. Dr Parson gave assurances that this would not happen, and that any transfer required would be a deferred decision by a Geriatrician.

The Chairman concluded by welcoming all of the work undertaken to date to establish the ICN. He stated that much good and innovative work had been done and was encouraged to hear of the involvement of the third sector. He asked that an update report be brought to the Board in March 2017, with an emphasis on cross border flows. 

RESOLVED that an ICN update report be brought back to the HWB in March 2017.