Integrated care pilot programme—UK Department of Health

Introduction The NHS Next Stage Review set the direction for a more locally-driven NHS, with quality as its organising principle. It also highlighted the need for improved integration between health and care services, to improve access to and quality of care within local communities. This was followed, in High Quality Care for All, by a commitment to test and evaluate a range of models of integrated care that should help improve patient, carer and service user outcomes. About the ICP The programme of integrated care pilots (ICP) has been established to address that need. It is an exciting and innovative way of exploring the benefits that greater integration could deliver for local health and well-being. ICP is designed to examine different ways in which health and social care could be provided to help drive improvements in local health and well-being. It allows communities to take a fresh look at how to deliver such care, based solely around the needs of the local population. The aim is to look beyond traditional boundaries (e.g. between primary and secondary care) to explore whether new, integrated models can improve health and care services. Each pilot will be exploring a new approach to a key health issue within the local community, and seeking to deliver improvements in quality, service user satisfaction and local health and well-being. Although the pilots have designed new models for delivering care, they must also ensure that key features of the current health systems are safeguarded, e.g. choice, competition, and the role of the Primary Care Trust (PCT) as the commissioner of local health services. The pilots will run for two years and will be evaluated over three years against a set of national and local measures. The criteria involved include impact on health outcomes, improved quality of care, service user satisfaction, and effective relationships and systems. ICP sits alongside other programmes, such as practice-based commissioning (PBC), to inspire innovation in service development and to encourage stronger partnership between clinicians and those working in local government and social care. It is an exciting opportunity to help deliver better health, better care and better value for local populations and for taxpayers. The pilot sites Table 1 summarises information of each of the selected pilot organisations. International innovations in integrated care Alongside the work being undertaken in the pilot sites, the DH is carrying out a review of international exemplars in integrated care. The evidence from these will be used to stimulate further development within the NHS. This is supported by a learning network encouraging local, national and international co-operation and collaboration. For further information ICP presents a major opportunity to explore new and exciting models of developing and delivering care services for local communities. If you could like any further information about the programme, please contact the Integrated Care team at the Department of Health, on integratedcare@dh.gsi.gov.uk and http://www.dh.gov.uk/en/Healthcare/IntegratedCare/DH_091112.

ICP is designed to examine different ways in which health and social care could be provided to help drive improvements in local health and well-being. It allows communities to take a fresh look at how to deliver such care, based solely around the needs of the local population. The aim is to look beyond traditional boundaries (e.g. between primary and secondary care) to explore whether new, integrated models can improve health and care services.
Each pilot will be exploring a new approach to a key health issue within the local community, and seeking to deliver improvements in quality, service user satisfaction and local health and well-being. Although the pilots have designed new models for delivering care, they must also ensure that key features of the current health systems are safeguarded, e.g. choice, competition, and the role of the Primary Care Trust (PCT) as the commissioner of local health services.
The pilots will run for two years and will be evaluated over three years against a set of national and local measures. The criteria involved include impact on health outcomes, improved quality of care, service user satisfaction, and effective relationships and systems.
ICP sits alongside other programmes, such as practice-based commissioning (PBC), to inspire innovation in service development and to encourage stronger partnership between clinicians and those working in local government and social care. It is an exciting opportunity to help deliver better health, better care and better value for local populations and for taxpayers. Table 1 summarises information of each of the selected pilot organisations.

Pilot name Details of pilot
Bournemouth and poole teaching pCt this pilot will be exploring a new model for delivering care for older people with dementia, involving collaboration between Gps, public sector organisations and third-sector services. It aims to provide a single point of access to an integrated community team.
Cambridge assura LLp this pilot will look at how different organisations across the health, social care and third sectors can better communicate and co-ordinate end-of-life care to enable people to be cared for and die in the place they choose. the pilot will also be improving public and patient engagement to ensure services are fully sensitive to user needs.
Church view medical practice this pilot will improve quality of care and experience of services for the area's population of older people. the local acute trust and Gp practice will work together as an integrated organisation, and will work in partnership with the pCt provider arm, social services and the patient practice group. the pilot will aim to provide an improved, personalised experience through active management of long-term conditions. NHS Cumbria this pilot will be exploring a new approach to helping patients with chronic diseases to manage their own care. It will be focusing on increasing the collaboration between Gp and patient. It will aim to move care into a community setting and reduce hospital admissions.

Durham Dales
Integrated Care Organisation this pilot will involve seven partner organisations working together to meet the needs of a rural population, provide continuity of care and reduce health inequalities. It will explore a number of different care pathways aiming to improve planning information, move care into a community setting, increase patient/carer satisfaction and reduce hospital admissions. North tyneside this pilot will provide an improved preventative service for over 60s at risk of falling by broadening the current falls and blackout (syncope) service provision. It will enhance provision and access to care and establish a network of communitycentred training services led by clinicians, in partnership with the third sector and other agencies. By developing these community services the pilot aims to reduce the number of falls and admissions to hospital.
Cornwall and Isles of Scilly pCt this pilot will unite primary, secondary, health and social care services by setting up a Gp-led memory clinic supported by a team of practice-based case managers and dementia care advisers. It will seek to increase the number of people receiving an early diagnosis, reduce admissions to hospital and care homes and see people maintaining independent living for longer.

NHS Norfolkand
Norfolk County Council the focus of this pilot will be on integrating care services for the elderly. Joint working between the pCt and the County Council will identify people in need of support and then work with them to develop personalised care plans. It aims to help elderly people live fulfilling and independent lives and to form care plans that meet the needs of both patients and carers.

Northumbria
Health care NHS Foundation trust this pilot will be exploring a new approach to helping patients with chronic obstructive pulmonary disease (COpD) to manage their own care. the pilot will ensure providers work together to co-ordinate care, provide consistent information and education and help patients manage their own care (with assistance from their key worker). the pilot aims to increase patient satisfaction, reduce hospital admissions and reduce the length of stay in hospital when admission is required.
North Cornwall practice-Based Commissioning Group this pilot involves 10 Gp practices in North Cornwall working together to integrate mental health community teams, based in a rural location, with a single point of access from Gp practices. It will integrate mental health acute and social services. the pilot will aim to dissolve boundaries so patients can more easily navigate through the system and ensure they 'only have to tell their story once'.

principapartners in Health
this pilot is designed to help create more informed and empowered COpD patients. It will involve partners working together through two projects to identify 'at risk' patients, and work with teams in community wards and with other partners involved in COpD treatment to integrate care along the clinical pathway. It is designed to improve co-ordination of care, increase patient satisfaction and reduce hospital admissions.
NHS tameside and Glossop this pilot will be seeking to change behaviour amongst people at risk of cardiovascular disease (CvD). It will involve developing partnerships to identify 'at risk' residents, supporting them with diagnosis/treatment but also promoting self-care and behaviour change. the aim is to reduce the risk of CvD (and reduce mortality rates for patients who have contracted it), improve the patient experience and reduce visits to outpatient clinics.
torbay Care trust this pilot will be integrating care for the elderly so that it is personalised and tailored to individual needs, secures best possible outcomes and ensures best use of resources. It will involve partner organisations across primary, secondary, social care and mental health services focusing on the whole care pathway, seeking to deliver highquality, safe, and reliable services for patients across the spectrum of care.
tower Hamlets pCt this pilot will be helping patients with long-term conditions to manage their own care. It will help patients make their own choices, with support from a range of diverse services and specialists locally. It will aim to improve health and well-being for patients with long-term conditions, increase uptake of services from targeted hard-to-reach groups and reduce the expected trends in long-term conditions.

Wakefield
Integrated Substance misuse Service this pilot will integrate care in the context of a substance misuse and social reintegration service for vulnerable people. It will involve a partnership of NHS, third sector and wider stakeholders and aim to make measurable improvements in the 'care experience' for substance misusers, creating integrated pathways that are both personalised and cost efficient.