The case for joined-up care

Implementing joined-up, integrated care is about improving people’s lives and delivering better outcomes. This is based on a broad view of health and wellbeing – including personal dignity, individual control over day-to-day life and participation in work, education, training or recreation, as enshrined in the Care Act 2014.

Today, people are living much longer, and often have highly complex needs and multiple conditions. These needs require ongoing management from both health and care services, which combine both the medical and social models of care. As our population ages and the financial pressures on the health and care system increase, we need to be better at providing proactive, preventative care in community settings, so that people can be supported to live at home for longer and avoid the need for commissioned health and care services.

Having a clear plan to develop joined-up care is a key requirement of the Better Care Fund policy framework and is a central theme of the NHS Long Term Plan.

Properly integrated care will help countless individuals throughout the country who currently may have to tell their story multiple times to lots of different professionals, may not be able to receive care at home when they want to, or may be passed from service to service, rarely being asked about what is important to them.

Making this happen demands a fundamentally different approach that responds to what people want and need, rather than simply offering whatever services are available.

People – whatever their roles in using, delivering or planning services – are central to developing an integrated approach.

In this guide we use the term ‘joined-up care’ to describe how different health, care and other services are brought together to meet the needs, choices and aspirations of the individual. This is based on the narrative of person-centred coordinated care developed by National Voices and others.

Person centred coordinated care chart showing the quote, I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me. The following statements are attached to the quote, My goals/outcomes, transitions, decision making, communication, information, care planning.

Source: National Voices’ vision for person-centred coordinated care (National Voices)

Building blocks for effective, sustainable change

There is no ‘one size fits all’ generic model that can be rolled out across the country. Local needs and circumstances vary, so each area will need to establish its own placebased approach. In this guide we help you to explore practical steps for how to achieve joint working through genuine partnership between senior leaders and managers, councillors and boards, community leaders and a range of frontline professionals and staff. The guide focuses on the key building blocks for effective joint working:

How to...lead and manage better care and How to...bring budgets together and use them to develop coordinated care provision highlight the importance of common themes such as building trust to cementing strong relationships, being clear about accountability, and systems leadership at every level in taking forward change. All of these components are essential to support effective joint working.

Valery was referred to Health as a physio referral for ‘confidence building on stairs’, our integrated triage function identified that she was already known to Social Services and has a stairs assessment booked the following week. Through discussing her case jointly, it was established that Valery was actually bed-bound and needed support to get out of bed. The Intermediate Care Team prioritised her case and arranged for an occupational therapist to complete a joint visit with the Social Services occupational therapist in order to prescribe some basic physiotherapy exercises.

Jo Frazer, Head of Kent Adult Social Care and Health PMO / STP Partnership Lead

How to... work together to achieve better joined-up care
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