Integration collaboration and pioneers

I can plan my care with people who work together to understand me and my carer(s), allowing me control, and bringing together services to achieve the outcomes important to me.

Definition of integration developed by National Voices
Integrated care and support: our shared commitment

National collaboration for integrated care and support

Fourteen of the major national health and social care agencies – including SCIE - established a national collaboration on integrated health and social care. We have committed to helping local organisations work towards providing more person-centred, coordinated care for their communities.

In May 2013, the collaboration partners published Integrated care and support: our shared commitment. This framework document sets out how local areas can use existing structures such as Health and Wellbeing Boards to bring together local authorities, the NHS, care and support providers, education, housing services, public health and others to make further steps towards integration.

Integration pioneers

The national collaboration asked local areas to step forward to be selected as pioneers, and we committed to giving them dedicated central support in overcoming the barriers to delivering innovative integrated care and support.

This resulted in over 100 expressions of interest to become a pioneer. The selected pioneers underwent a rigorous selection process, including a face-to-face interview, and the final selection was made by a panel consisting of representatives of each of the national partners as well as domestic and international experts.

The 14 successful integration pioneers announced on 1 November 2013 are:

SCIE support for pioneers

Lord Michael Bichard, Executive Chair, Social Care Institute for Excellence welcomed the announcement of the pioneer sites saying:

There is broad consensus from people who use, provide and commission services that more integrated care is better and more cost effective. The challenge now is how to do it well. The Social Care Institute for Excellence welcomes the opportunity to support and learn from the integration pioneers. In particular, we will share our knowledge about how to tackle the barriers to integration through our new online tool – Integration: step by step.

SCIE will support the integration pioneers by supporting the leadership development aspects of the programme and providing access to our range of integration related tools and resources including:

Role of the pioneers

The pioneers will act as exemplars to address local barriers to delivering integrated care and support, and highlight national barriers that the national partners can work to address. The pioneers will support the rapid dissemination, promotion and uptake of lessons across the country. They will be offered central support to breaking down barriers by the national partners. This support will be provided by the national partners through NHS IQ who will also support the sharing of learning nationally, to support all areas and make progress at scale and pace in overcoming the barriers to integrated care and support.

Through breaking down the barriers to integrated care and support not only in the pioneer areas, but nationally, the partners aim to make integrated care and support the norm, and to improve the experiences of patients, service users and carers through better coordinated care. For those localities not selected as pioneers, the partners are keen that plans are still realised and that all areas can benefit from the wider programme that the national partner organisations are undertaking.

Related information

Integrated care and support: our shared commitment May 2013

Department of Health press release: Integration pioneers leading the way for health reform - 1 November 2013

SCIE work on integration

The Integrated Care and Support Collaborative

Fourteen national organisations who are the leaders across the health and social care system have come together to support local areas in their efforts to achieve integrated care and support over the next few years. The Collaborative currently involves:

The Integration Transformation Fund (ITF)

On 26 June 2013 a £3.8bn Integration Transformation Fund, a pooled fund between local government and health to promote better integration between health and care services, was announced as part of the Spending Review. The £3.8bn fund will provide the biggest ever financial incentive for local areas to integrate services in a way that improves outcomes and experiences for individuals. National partners are working to decide the best approach for the implementation of the Integration Transformation Fund, including whether this requires further primary legislation.

Through acting as exemplars of the most innovative approaches to integrated care and support, the pioneers will help all areas in shaping and delivering on their joint plans for implementing the Integration Transformation Fund at the local level. The Integration Transformation Fund will provide the biggest ever financial incentive for integration across the country. This will encourage all areas to utilise the learning shared from the pioneer programme, and benefit from the barriers that have been broken down by the pioneers with the support of the national partners.

Integration pioneer sites

Locality Partners, population Client Group Key Features
Devon and Torbay Torbay Council, Devon County Council, South Devon Healthcare NHS Foundation Trust, Torbay and Southern Devon health and Care Trust, Devon Partnership NHS Trust, Rowcroft Hospice; population 1.2 million Original work focused on frail elderly. Now looking to roll out to wider population Young people: primary mental health worker in GP practices, targeted screening, preventive work in classrooms; community based model for managing long term conditions, plan to extend from 0.5% to 5% of those most at risk (includes virtual ward and hospital at home); health and wellbeing for carers; Delivered through community hubs, with 7 day services across all health and care services.
North West London Led by North West London collaboration of CCGs (8). Supported by North West London local authorities (7), NHS provider trusts (9) wider partner organisations. Population size 2.2 million Older people, children, mental health, learning disability Overarching programme to deliver an integrated care system to deliver better outcomes for local populations. Lead role for GP's who will be the hub of coordinated care delivery.
Worcestershire Worcestershire CCGs, Worcestershire County Council, Age UK Herefordshire and Worcestershire. Population size 570,000. Older people, mental health. Learning disability. Comprehensive programme of service integration focusing on community provision to promote health and well-being and support people with long term conditions. Clustering of services around GP hubs. Defined role for the voluntary sector.
Cornwall Cornwall County Council, NHS Kernow, Council of the Isles of Scilly, Royal Cornwall Hospitals Trust, Cornwall Partnership Foundation Trust, Peninsula Community Health, Peninsula Medical School, HealthWatch Cornwall, HealthWatch Isles of Scilly, South Western Ambulance Service, BT Cornwall, Volunteer Cornwall, Cornwall Carers Service. Population covered 116,000 1) People with long term illnesses/ the frail elderly 2) People at the early stages of illness or frailty (eg dementia) 3) people at risk from inequalities and lifestyle choices GP led, with integrated care teams structured around locality groups of GPs. Newquay Pathfinder piloted the approach. Care shifted from dependency on acute to community/VCS involvement. For 1) Whole system model for intensive support and rapid response including frailty pathway, urgent care, rapid access eldercare, virtual care homes. For 2) dementia service, early intervention, community, falls prevention to test whole system model in a locality. For 3) (slower track) review existing services and spend then co-design new service
Islington Islington CCG and Islington Council. Population size 220,000. Target population 58,000> Older people and mental health. Support for people with long term conditions and mental health needs to be involved in the development of and receive personalised care and support services. Focus on addressing wider determinants of health and using community assets. Key role for public health
London WELC Waltham Forest, East London and City Care Collaborative. 3xCCGs, 3xLondon boroughs, Bart's Health, MH trusts, UCL Partners 20% of population as defined through risk stratification. Combining physical, mental health and social care. (Strong mental health component) Care navigation, one navigator for each patient. Interventions cover self-care, care co-ordination and ensuring people are in the most appropriate setting. Essential components include information sharing platform, joint assessments, creation of new roles in the workforce and organisation of GP practices into networks.
Greenwich Royal Borough of Greenwich; Greenwich Action for Voluntary Services; Oxleas NHS Foundation Trust; Greenwich CCG; Healthwatch Greenwich; Lewisham Healthcare NHS Trust; borough population 254,000; test site in Eltham 54,000 Mental health fully embedded. Advanced dementia service links community and mental health teams. Integration in all health and social care services, based around a hub of GP practices. Will co-ordinated resources across health, (acute, primary, community) and social care. Comprehensive service in place in test site by April 2014; rolled out thereafter. Model has already been shown to have reduced hospital admissions.
Leeds Leeds City Council. Large number of partners across commissioning, providers, local and third sector, PPI, Unions. Population size 800,000 Integration focused on wellbeing, prevention and early intervention. All adults and children (focus on those with complex needs). Young children: 'Early Start Service' in 25 localities for health, social care and early education. Adults: 12 co-located integrated health and social care neighbourhood teams for needs of older people and those with LTCs. Link to GP clusters, focus on those identified through risk stratification as most likely to benefit from early intervention to prevent deterioration of health
South Tyneside Led by South Tyneside Council. Supported by South Tyneside's CCG, NHS Foundation Trust and Northumberland Tyne and Wear NHS Foundation Trust. Population size 148,000 with target group of 24,400. Older people Developing new approaches to early help, prevention, self-care, and integrated support services. Aim to comprehensively implement: risk stratification tools in primary care, lifestyle support programmes, recovery services and integrated support models.
North Staffs Macmillan Cancer Support; North Staffordshire CCG; Stoke on Trent CCG; East Staffordshire CCG; Stafford and surrounds CCG; population 1 million Cancer and end of life care (all long term conditions) Redesign of pathway for cancer and end of life care, bringing together most specialist with community/primary care. Earlier diagnosis, better prognosis, choice of place of death; carer support, control
Southend Led by Southend on Sea Borough Council. Supported by Southend CCG, South Essex and Southend Foundations Trusts. Population coverage 176,000 Older people, mental health, learning disability. Integrated service delivery model underpinned by single access and referral routes and multi-disciplinary teams in primary care. Development of community based services to avoid the need for hospital care.
Cheshire Led by Cheshire West and Chester Council. Supported by Cheshire East Council, South Cheshire, Vale Royal and West Cheshire CCG's. Population coverage 699,000. Older people, mental health, learning disability. Build an integrated communities approach and a service delivery model of integrated case management.
Barnsley HWB, Barnsley CCG, Barnsley MBC, Barnsley Hospital NHS FT, SW Yorks Partnership FT, NHSE LAT, South Yorks and Bassetlaw; HealthWatch Barnsley; S Yorks police. Population size: 231,900 Services to all client groups, including stronger families and troubled families programmes, Three elements: 'Inverting the triangle' to shift focus to prevention and early integration; joining individual integration elements; 'Fast track enablers', including telehealth and telecare; supporting families; community level bringing together voluntary services and residents to co-produce the specification for services needed.
Kent Kent County Council, Kent CCGs ,East Kent hospitals trust, Kent and Medway commissioning support unit, Kent Community trust, Kent and Medway commissioning support unit and social care partnership trust, Swale Borough Council. Population size 1,480,200. Older people, mental health, learning disability. Redesign of integrated commissioning , maximise opportunities through community budgets, oversee substantial reductions in unscheduled care activity through effective community management of long term conditions