The following is an overview of the key areas of improvement:

  1. Integrated community networks (ICNs): We will establish teams of nurses, social workers, voluntary sector and mental health around groups of GP surgeries, called networks. The team will work with people and families to support them in staying healthy and independent and provide proactive support to people at risk or in times of crisis. These networks will also provide direct links to community networks and voluntary / third sector groups. The idea is to ensure that through a network of heath / care workers, we will be able to provide the right support to the individual and family.
  1. ‘My Life’ plan: We will move from creating a care plan to co-developing a ‘My Life’ plan with people, carers and families. The multidisciplinary team, GPs and independence coordinators will support the person in defining and developing how they wish to shape their life. We will focus beyond the traditional medical and care aspects to working on lifestyle, community integration, self-care and providing the right information and tools that can enable the person to decide and shape their life. The ‘My Life’ plan aims to move from a health centred care plan to a more holistic and personalised plan that people decide for themselves based on what matters for them the most.
  1. Personal independence coordinators: Feedback from people in Croydon emphasised the need to have ‘someone to talk to when needed’. We will aim to have a personal independence coordinator (PIC) for people who need individualised support to help with the development of ‘My Life’ plans and coordinating and establishing links with the right services and support networks in the community.
  1. Points of access to information and support: We will establish points of access; one in each network manned by trained voluntary staff who can offer impartial advice and referrals to help with all of a person’s needs. This will include council issues, medical issues, financial issues, social issues and more.
  1. Integrated independent living service: The integrated independent living service will be an integrated team of workers such as therapists, home safety risk assessors, telecare (devices that help monitor and manage conditions remotely), home based care support, doctors and nurses. The team will work jointly to provide proactive support in times of crisis and focus on getting the person back to the best possible state of independence. The fact that the services will work in an integrated way means a person will have to tell their story once.

 

It is important to recognise that these initiatives are in a state of development and will commence staged implementation in 2017/18. We will be working with people and front-line workers in shaping this further.