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The benefits of Integrated Care Decision Making

We are bringing together teams of health, care and voluntary sector professionals to work together, to provide tailored services to individuals in their own homes. This enables teams to work flexibly, focused on the person’s needs and not on organisational boundaries or responsibilities.

Various steps have been taken to provide a consistent service across the ICS:

  • In East Berkshire, there has been a rollout of anticipatory care planning, identifying people living with frailty earlier and enabling planning and crisis prevention. The membership of the multidisciplinary team has also been extended in East Berkshire, leading to accelerated performance improvements. Community Integration Managers are currently being recruited in East Berkshire to drive cultural and operational change.
  • The Surrey Heath frailty model has been identified as national best practice exemplar and nominated for several awards including the BMJ Award for ‘Care of the Older Person’
  • In North East Hampshire and Farnham, Anticipatory Intervention Meetings have been setup in each of the localities as well as implementation of Locality Access Points, enabling streamlined assessment and holistic response to needs at point of referral.
  • Frailty services are now established at both Frimley Park and Wexham Park hospitals, leading to more patients being able to return home within 72 hours.

A Frailty Advisory Board has been established and there has been enhanced engagement of general practice and local partners in the establishment of a place-based integrated care model and the embedding of multi-agency care planning.

Fiona Slevin-Brown, Director of Strategy and Operations, NHS East Berkshire CCG and the Responsible Officer for the Programme has said: “We have heard from patients and carers and understand how important a coordinated approach is to someone’s care. We are really proud that the changes we have made so far are making a real difference to patients’ lives.

She added “Multidisciplinary teams are made up of  a range of professionals including GPs, community nurses, social care professionals mental health practitioners, and clinical pharmacists as well as third sector  representatives, and their focus is on  the person as a whole and supporting them appropriately.”

So far, in terms of impact we have seen:

  • Happier patients: Increased number of people reporting feeling happier and less worried. Wider families and carers, individuals and families are less worried and know how to access support they are confident in.
  • Healthier communities: Reduced A&E attendances and emergency admissions and readmissions. Providing confidence to receive care and be supported in people’s own homes.
  • Better use of resources, through more timely care in the most appropriate setting
  • Motivated workforce: Increased number of staff feeling more confident at work and having increased work satisfaction.


Frimley Health and Care