Our integrated care system

Whole system overview image.pngAn integrated care system is when all organisations involved in health and social care work together in different, more joined-up ways.

The focus is on providing care in a way that benefits patients - not what is easiest for organisations.

From family doctors, to mental health staff, community teams and our major hospitals, we’re going to be pooling our resources, skills and expertise to make care and support better for our residents.

In Kent and Medway all the NHS organisations and the Kent and Medway councils have been working together as a sustainability and transformation partnership (STP) since 2016. In April 2021 NHS England formally accredited the Kent and Medway as an Integrated Care System.

Government proposals set out in a White Paper in February 2021 will see further changes from April 2022, which we are developing local plans for - subject to new legisaltion going through Parliament during 2021/22.

“We will work together to make health and wellbeing better than any partner can do alone”

This means we will:

1. Give children the best start in life and work to make sure they are not disadvantaged by where they live or their background, and are free from fear or discrimination.

2. Help the most vulnerable and disadvantaged in society to improve their physical and mental health; with a focus on the social determinants of health and preventing people becoming ill in the first place.

3. Help people to manage their own health and wellbeing and be proactive partners in their care so they can live happy, independent and fulfilling lives; adding years to life and life to years.

4. Support people with multiple health conditions to be part of a team with health and care professionals working compassionately to improve their health and wellbeing.

5. Ensure that when people need hospital services, most are available from people’s nearest hospital; whilst providing centres of excellence for specialist care where that improves quality, safety and sustainability.

6. Make Kent and Medway a great place for our colleagues to live, work and learn.

The integrated care system is a partnership of all parts of the NHS workign together with councils and other partners.

Within the NHS there are three key groupings working at different geographies. The terminology used for the three levels is neighbourhood, place and system:

  1. Forty two primary care networks across Kent and Medway. A primary care network (PCN) consists of groups of general practices working together, and in partnership with community, mental health, social care, pharmacy, hospital and voluntary services in their local area, to offer more personalised, coordinated health and social care to the people living in their area. 
  2. Four integrated care partnerships drawing together all provider NHS organisations in a given area and working more closely with social care.
  3. a single commissioning group for Kent and Medway, led by local doctors, to take a bird’s eye view and look at where we can tackle shared challenges together such as cancer and mental health.

Changes proposed in the Government's White Paper (Feb 2021) would see the Clinical Commissioning Group replaced by a new NHS statutory body and the creation of a new partnership group. More details on these proposals will be added shortly.

The ICS partnership board currently includes representatives from:

  • Dartford and Gravesham NHS Trust
  • East Kent Hospitals University NHS Foundation Trust
  • Kent and Medway NHS and Social Care Partnership Trust
  • Kent Community Health NHS Foundation Trust
  • Maidstone and Tunbridge Wells NHS Trust
  • Medway NHS Foundation Trust
  • Medway Community Healthcare
  • South East Coast Ambulance Service NHS Foundation Trust
  • Healthwatch
  • Kent County Council
  • Medway Council
  • Kent Local Medical Committee
  • NHS Kent and Medway CCG
  • NHS England and NHS Improvement – South East Region

The system transformation partnership, and now the integrated care system, aims to tackle a range of challenges to improve health and care for residents across Kent and Medway.

The number of people living in Kent and Medway is predicted to rise by almost a quarter by 2031.

We spend just £86m (2%) of our budget supporting people to stay well and prevent illness, compared to £3.4 billion treating ill-health.

Over 528,000 people - that’s almost one in three - live with one or more significant long-term health conditions, including around 12,000 with dementia.

People with a serious mental illness die on average 15 to 20 years earlier than the general population.

If staffing was in line with the national average, there would be 175 more GPs in Kent and Medway. Over half our practice nurses could retire in 10 years.

Evidence shows, every day, about 1,000 people in Kent and Medway are in a hospital bed when they no longer need to be.

In addition to these challenges, which existed before the pandemic, we must now work together as a system to recover from the pandemic and ensure we take the opportunity to address health inequalities which Covid-19 has shone a spotlight on.

These priorities have been agreed with by the Kent and Medway ICS Partnership Board

1. Restart and Recover – a systematic approach to restarting services that were disrupted during the first COVID-19 peak and in transforming to the system we want to be. Elements of the programme include: a focus on the enablers and levers for lasting change; addressing the impact of COVID-19 on BAME communities; clinical input to the plans for restarting and recovery; recognising the importance of impact of COVID-19 on staff and the need to support staff resilience; supporting meaningful development of out-of-hospital care for the longer term; preparing for any further surge in COVID-19.

2. System leadership and development – a clear focus on ICS development and approval moving to deeper system working including Integrated Care Partnership (ICP) and Primary Care Network (PCN) development and assurance and effective interactions between the layers of the ICS in terms of accountability, responsibility, support and facilitation.

3. Strategic change

  • Starting the process for review of service delivery across Medway, north Kent and west Kent with a focus on development of organisational alliances and clinical networks.
  • Progress and deliver the East Kent pre-consultation business case (PCBC) and consultation process.

4. Performance – develop a revised performance improvement approach in challenged organisations with better alignment of energies and activities across CCG/ICS and regulators; system approaches to improvement beyond single organisational boundaries; and incorporation of local system support from other organisations to support improvement.

5. Develop a clear approach to improvement – commitment to, and adoption of, single methodology and philosophy (Quality, Service Improvement and Redesign (QSIR) is currently the predominant model in Kent and Medway); develop capacity and capability at all levels of the ICS; change in culture for increased focus on experimentation and rapid improvement cycles.

6. Ensure a focus on key system enablers – strategic attention to digital (including shared data and analytics) and workforce aligned to focused initiatives within priority development areas to ensure this is translated into real change and moves beyond strategic intent.

  • More support to stay fit and well before things become a problem.
  • Better access to the care you need, when you need it, in a way that suits you: evenings, weekends, over the phone, by video link or face-to-face with a physio, nurse, clinical pharmacist, GP, or support from a non-medical service.
  • More focus on your physical and mental health and wellbeing – on what matters to you, not the condition or disease that you may have.
  • More care out-of-hospital, with staff working together as a single team across organisations to help people stay as well as possible and get the care they need when they need it.
  • Better identification of the issues that need tackling and a real focus on quality services, wherever they are provided.

  • Higher job satisfaction as working in teams is less isolated and more rewarding.
  • Better work/life balance with each professional able to focus on what they do best.
  • Greater resilience and less risk of burnout.
  • Greater influence on how resources are used to best effect for patients.

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