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3.3.3 Lack of Integrated Care Pathways

A lack of co-ordination between health and social care systems has led to

poorer outcomes for patients as opportunities are missed to prevent avoidable

escalation of healthcare needs. This is a particular concern for the older

population who often have long-term and complex medical conditions requiring

multiple interactions with various parts of the system. The Department of Health

estimated that people with one or more long-term condition cost NHS England

about 70 per cent of their budget but account for only 30 per cent of the


It is clear therefore that integrating care would not only improve patient

outcomes but would also save considerable money. There are already a few

pilot schemes that attempt to introduce more integrated care-in the form of

what are called Integrated Care Pathways (ICP). One such example is the two

North West London Integrated Care Pilots that cover inner and outer London

which were established in 2011. Three key elements to this and other ICP

pilots are the provision of multi-disciplinary teams, information sharing between

services and named care co-ordinators for each patient.

The North West London ICP pilot in particular improved outcomes for old

people. 77 per cent of elderly patients in the pilot were screened for their

risk of falls and 69 per cent were screened for cognitive decline allowing for

proactive discussions with multi-disciplinary teams about how to manage health

in the future. Such screening had a significant short-term impact on institutional

care with a 15 per cent reduction of non-elective admissions in those aged over

75 in 2011-2012 and a 14 per cent decrease in emergency activity in inner

North West London. It will also have a long-term impact on institution care as

88 per cent of patients in the pilot had discussed their health goals for the future

and had developed a future action plan to reach these goals and 38 per cent

of patients had started anticipatory care planning.65

Whilst this sort of approach to addressing the demand coming in through

hospital front doors shows promising results, it remains very much the exception

rather than the rule. In the future much greater use of integrated care pathways

64 Department of Health, Long

term conditions compendium

of information third edition (30

May 2012)

65 LGA, Integrated care value case

North West London, England

(October 2013)

Chapter 3 - What Is The Diagnosis? Or Why Are We Failing Our Elderly?


consisting of a variety of professionals from both Adult Social Care and

Health, including District Nurses, Social Workers, Community Matrons, Care

Coordinators and other specialised services, are already fundamentally closing

the 'gaps' that used to exist in service provision.

• Development of an integrated 'Front of House' - ensuring that there is

a co-ordinated approach to signposting, assessment, triage and support

management in partnership with voluntary and community sector groups.

• Transitional Care and Support to Acute Services - implementing a new,

radical approach to care categorisation, fundamentally shifting support

to home and community based support and away from the hospital.

The result has been a significant increase in the effective time spent in

delivering transitional care services, in particular reablement, and a clear

ongoing improvement in patient, client and staff satisfaction across their

communities and within the organisations involved.


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