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Involvement opportunities

Care Navigation

1. Overview and background

Ealing CCG serves a registered population of 420,000, managing an annual budget of almost £415 million, across an area diverse in terms of wealth, deprivation and health. An increasing proportion of this populous is reaching, or has reached, the age of 75 or has needs which are either complex or difficult for them to effectively self-manage. In addition many of these patients are deemed to be ‘hard to reach’ for a variety of reasons and find it difficult to navigate the sometimes complex range of medical health and social care needs and requirements. Some of these difficulties are because of a lack of connection between health and social care provision as well as the sheer number of organisations offering differing types of care which they may be required to access.

Ealing CCG is made up of 77 GP member practices that in 2014/15 served an estimated registered patient population of 420,2561. We are committed to improving the care provided to patients, reducing health inequalities and raising the quality and standards of GP practices whilst achieving a financial balance.

Our aim is to ensure that the highest quality of care is delivered by those organisations best qualified to do so for the diverse needs of our patients, carers and the public, and at the best value for money so that we spend public money wisely.

Populations are aging, with the number of individuals with long-term conditions increasing. At the same time, the money available to fund health and social care is tightening. NHS England’s Five-Year Forward View says that, in order to meet the need of patients and sustain the NHS, it needs to move away from being a “care and repair” service and put much greater emphasis on engagement and prevention, as well as empowering patients to take a much more active role in self-care and maintaining their well-being, with support from the NHS.


Whole Systems Integrated Care

The vision for whole systems integrated care is based on what people have told us is most important to them. Through patient and service user workshops, interviews and surveys across North West London, as well as through the National Voices’ narrative, we know that what people want is choice and control and for their care to be planned, with people working together to help the patients reach their goals of living longer and living well.

Achieving our vision of whole systems integrated care in North West London will, therefore, mean re-shaping the way care is provided, in order to promote behaviour change in both patients and clinicians so that every opportunity is taken to support patients to actively be involved in managing their health. The aim is for a truly person centric service facilitated by care navigation and care coordination services.

As part of enabling individuals and their families/carers, patients must be given access to consistent guidance about where to seek help. Through whole systems integrated care, we want to improve our ability to work together in co-ordinated teams, thus improving the experience of care and the outcomes we achieve, as well as achieving financial sustainability for the system.


Care Navigation

As the number of healthcare professionals, care settings and treatments involved in a patient’s care has increased, the navigation of care has become both more difficult and more vital. Effective care navigation ensures that patient and family needs and preferences for care are understood, and that accountable structures and processes are in place for communication and integration of a comprehensive plan of care across providers and settings. Care among many different providers must be well co-ordinated to avoid duplication and waste and conflicting plans of care.

Care navigation is especially important for people with chronic conditions and the elderly. As this ever-growing group attempts to navigate our complex healthcare system and transition from one care setting to another, they often are unprepared or unable to manage their care. Incomplete or inaccurate transfer of information, poor communication and a lack of appropriate follow-up care, can lead to confusion and poor outcomes, including medication errors and often preventable hospital admissions and A&E visits.

Care navigation is defined as “a function to help ensure that a patient’s needs and preferences for health services and information sharing across people, functions and sites are met.” The CCG anticipates that it will also be used to support care planning and the wider preventative/self-care agenda.

1. This navigation of services and sessions will be provided by the Ealing Care Navigation Service which is an initiative arising from the Whole System of Integrated Care (WSIC) programme. This programme aims to bring care closer to service users, reduce the need for hospital stays and provides a holistic way of commissioning services in the CCG area.

2. The Care Navigation Service is expected to meet the needs of a cohort of up to eight thousand service users in the Ealing CCG area.