Together We’re Better leaders visit staff delivering integrated care

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Together We're Better's Chairman and Executive Director received a first hand look at how Integrated Care Teams are helping to improve services for the people of Staffordshire and Stoke-on-Trent.

Integrated Care Teams (ICTs) are being developed to:

  • Make it easier for health and social care staff to work across different organisations and with the voluntary sector
  • Be reflective of the needs of their population
  • Help people remain independent and at home for as long as possible

There are four early implementers across Staffordshire and Stoke-on-Trent - Leek/Biddulph, Lichfield/Burntwood, Longton/Meir and Stafford.

Together We're Better Chairman Sir Neil McKay and Director Simon Whitehouse visited two ICTs - the first visit at Adderley Green Surgery in Stoke-on-Trent, which is home to the Meir ICT site. They observed a multi-disciplinary team meeting where professionals from different organisations, including NHS providers of physical and mental health services, Stoke-on-Trent City Council staff providing adult social care and professionals from the voluntary sector, discussed service users on a case-by-case basis, assessing the most appropriate support for their needs. Working together they provide integrated care which reduces duplication and delivers the most effective outcomes.

The team explained that people cared for by the ICT are assessed through the use of a risk tool or by staff selecting individuals who they believe would benefit from a truly integrated model of care. More than 35 people are currently being treated by the Meir ICT.

Feedback to the team was extremely positive and they were encouraged to develop and deliver this way of working more widely across the local area. Sir Neil also shared the STP’s vision to see leadership, budgets and bases for ICTs in the future – described as a “really exciting prospect” by members of the team.

Sir Neil and Simon then travelled to Samuel Johnson Community Hospital in Lichfield where they met with staff and patients at the Frailty Hub, which forms part of the model for an ICT.

Colleagues used the opportunity to explain how and why the Frailty Hub has been created. Lichfield GP Dr Gulshan Kaul explained that the ICT is enabling professionals to “work in an integrated and co-ordinated way”, which is “identifying service users early enough to support their independence”. Similarly to the Meir ICT, the next step for the Frailty Hub is to ‘scale up’ to reach a wider proportion of the local population.

Reflecting on the two visits, Sir Neil said: “Our task is to develop a long term sustainable plan for health and care. The bedrock upon which it must be based is what you are talking about today.

“It is fantastic to see how on the ground the teams are working together to benefit citizens and we heard tantalisingly interesting discussions. We now want you to help the rest of our health and social care system in Staffordshire and Stoke-on-Trent to support this way of working.”

Lichfield MDT 2

Meir 5