Portal supports integrated care pilot

Wembley stadium, north west London.

A custom made information tool has been developed to support the work of a major integrated care pilot launched this week in north west London.

The North West London Integrated Care Pilot includes acute providers, general practice, community care, social care and mental health and aims to focus in its first year on improving care for 375,000 patients with diabetes and people aged 75 and over.

It will initially cover patients treated by Imperial College Healthcare NHS Trust, but Chelsea and Westminster Hospital NHS Foundation Trust is to join the pilot in the second year.

The ultimate potential catchment area is 750,000 patients, which makes it one of the largest projects of its kind in England, according to its leaders.

The project aims to improve patient experiences, ensure consistent use of guidelines, strengthen care co-ordination, reduce variations and gaps in care and prevent unnecessary admissions to hospital.

Savings from reduced attendances at A&E, as well as reductions in emergency admissions and lengths of stay, are predicted to reduce health and social care spend for people with diabetes by £2.1m after one year and £4.8m after five years.

The project also hopes to make savings on care for the elderly of £7m after one year and a further £5.4m over five years.

The information tool has been developed as a secure, web-based portal to support the project by enabling the sharing of patient level clinical and scheduling information.

It will also provide a patient-level business intelligence solution and co-ordinate care plan delivery across multiple clinicians and organisations.

Information input into the tool will include primary care data from TPP SystmOne, EMIS and Vision, community data sets from pro-wellness and RiO, activity data from Imperial College Healthcare NHS Trust and data from walk-in centres, out-of-hours providers and mental health providers.

The legal basis of consent for enabling risk stratification will be based on existing consent that GPs have to view their patient information and section 251 coverage of the Secondary Uses Service data.

For care plan management and viewing of integrated patient care history, GPs will be required to seek explicit consent at the time of creating a care plan.

GPs will be able to use the tool to see a glance the care being provided to their patients and isolate any reasons for gaps in their care and all healthcare providers will have access to patient clinical information from a range of different settings.

The tool will also enable the performance of GP practices and the performance of different multi-disciplinary groups to be benchmarked across a range of metrics using a performance scorecard.

Anne Rainsberry, chief executive of NHS North West London, said the cluster was delighted to be part of the pioneering initiative.

She added: “This pilot lays down key elements that are needed to make integrated care work, such as a collaborative culture where providers work together towards common goals, the involvement of patients making decisions about their own care and clinical leadership. We are confident that this approach will result in success and benefit all those involved.”

The pilot was also welcomed by Professor Chris Ham, chief executive of the King’s Fund, which has called for a greater focus on integrated care in its response to the government’s current listening exercise on the reform plans laid out in the ‘Liberating the NHS’ white paper.

He said clinically integrated care offered real benefits for patients and helped ensure that resources were used efficiency.

He added: “The North West London Integrated Care Pilot provides an opportunity to demonstrate these benefits for people with diabetes and frail older people. Its progress will be watched carefully as the NHS rises to the twin challenges of an ageing population and the increased prevalence of chronic disease.”

Finally, Mark Davies, chief executive of Imperial College Healthcare NHS Trust, said: "This completely new way of working. By breaking down artificial barriers across different parts of the health service, we aim to offer higher quality care in the most appropriate setting and improve the patient experience."