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Making services more effective and efficient through collaboration and integration

What are our overall aims by 2028?

Integrated Neighbourhood Teams (‘INTs’) are embedded across our four Places, bringing together the expertise and resources of health, care and VCFSE partners.  The INTs provide a focal point for connecting wider Place based integration involving the full range of partners (housing, employment, etc).

People with more complex needs, including those with multiple long term health conditions, receive more proactive, personalised care closer to home with support from a multidisciplinary teams working across professional boundaries as part of INTs. 

People stay healthier for longer within their local communities as a result of a focused and joined-up approach to prevention, and are supported to maximise their independence, wellbeing, quality of life and potential for recovery after an episode of ill health. 

People and communities are equal partners in how INT services are designed and delivered, ensuring that services are responsive to local needs and preferences. 

People thought to be in the last 12 months of life receive co-ordinated, proactively planned and personalised care for the end of life and are supported to be cared for and die in the place of their choosing, with bereavement support available to those important to them. 

What’s our starting point?

In 2018 we started a journey to implement a new model of out of hospital care in Coventry and Warwickshire.  Through our four Place based out of hospital contracts we have begun to redesign and integrate out of hospital services at PCN level. We have also established Urgent Community Response services to deliver urgent care to people in their homes if their health suddenly deteriorates. This work provides strong foundations for us to develop and deliver our local response to the vision for integrated out of hospital care set out in the Fuller Stocktake Report.  

Our 19 PCNs bring together groups of GP practices and other partners in local areas to deliver more proactive, personalised and co-ordinated care to people closer to home.  Supporting the development of PCNs is a central theme in our local Primary Care Strategy, which we will be refreshing to recognise both the Fuller Stocktake Framework for Shared Action and the significant progress made by local GP practices and PCNs in embedding collaborative working through the Covid pandemic. 


What are some of the key links to other parts of the plan?

Population Health Management – PHM will support INTs to identify and prioritise patients with more complex needs who will benefit most from proactive, personalised care.

Health Inequalities and Personalised Care – many of the projects funded through our local Health Inequalities Innovation Fund and our personalised care ‘demonstrator projects’ are based on collaborative working at Place level.

Supporting People at Home – work described in this section will be critical in supporting the delivery of our overall aims relating to supporting people at home.

Improving Access to Services - Urgent and Emergence Care – collaborative work will be happening in each  of our Places to develop integrated urgent care models in the community.

System Transformation – our two geographic Care Collaboratives will drive integration across services, with urgent care and out of hospital services being two of their initial areas of focus.


What will we be focusing on in the next 2 years?

During 2023/24, and through collaborative working between the ICB, the two geographic Care Collaboratives and the four Places, reviewing the four Place based out of hospital contracts – key activities as follows:
- Establishing a system wide Joint Review Group;
- Defining the scope of out of hospital services for the review;
- Reviewing current contract outcomes;
- Reconciling current service requirements against the latest national and local priorities, including the Fuller Stocktake Framework for Shared Action and the national Proactive Care Framework;
- Through Place based Working Groups co-producing an updated clinical delivery model;
- To inform and shape the above, undertaking a programme of public and stakeholder engagement. 

During 2024/25, mobilising the new out of hospital delivery models.

Refreshing the ICB Long Term Conditions Team work plan to ensure alignment to national priorities and Care Collaborative and Place priorities established through the out of hospital contract review process.

Developing and implementing a local Fuller Stocktake Implementation Plan, reflecting the outcomes of the out of hospital contract review process, and addressing the 8 action areas for ICSs identified in the Fuller Stocktake Framework for Shared Action.

Developing governance and oversight arrangements for the Fuller Stocktake Implementation Plan in collaboration with our two geographic Care Collaboratives and the Primary Care Collaborative.

Developing and implementing local plans to address the refreshed national Proactive Care Framework in collaboration with the out of hospital contract Lead Providers, building on progress to date through established local Ageing Well Programmes.

Developing and implementing the Coventry and Warwickshire Palliative and End of Life Care Strategy 2024-29 and delivering the Palliative and End of Life Care Action Plan 2023.

Refreshing the local Primary Care Strategy in the context of the Fuller Stocktake Framework for Shared Action and developing an aligned Delivery Plan.

Working with the Coventry and Warwickshire Training Hub to refresh the local General Practice Workforce Strategy and developing an aligned Delivery Plan.

Convening a sub-group of our Primary Care Collaborative to focus on PCN development.  Through this group, developing a process to deliver PCN Development Plans, which apply a maturity matrix approach, across all of our PCNs. 

Providing support for innovation and service improvement, and developing PCNs to enable rapid spread of innovation. Specifically we will co-design new commissioned enhanced services and models of care provision with a stronger focus on local clinical leadership and ownership.

Developing resilient infrastructure around our GP practices through the delivery of projects within our General Practice Estate and General Practice Information and Communication Technology Programme Plans, refreshing both Plans during 2023/24.

Establishing a system wide PCN Clinical Director and Aspiring Clinical Director Forum to support leadership development in the context of the development of INTs.


Key Challenges

Challenges described in the Supporting People at Home and Improving Access to Services - Urgent and Emergency Care sections will also impact on our ability to achieve the overall aims described in this section.

2023/24 is the final year of Investment and Evolution the national five-year contract agreement for general practice. The contract agreement for 2024/25 and beyond will be key in shaping local planning for later years of this plan.  In the absence of an agreed national position, the vision and direction of travel set out in the Fuller Stocktake will inform local planning. 

As reflected in the Fuller Stocktake Report, change and action is required at a national level across a number of areas to support ICSs to deliver the vision set out in the report – workforce and estates are two areas that are highlighted specifically. 


Key Metrics and Deliverables

Refreshed Coventry and Warwickshire Primary Care Strategy published by end of February 2024.

Refreshed General Practice Workforce Strategy published by end of September 2023.

Fuller Stocktake Implementation Plan developed by end of September 2023.

Urgent Community Response Team – 70% response within 2 hours.

Out of hospital contracts include 5 core domains – each domain has an aligned set of outcomes and indicators.  These will be reviewed and refreshed as part of the out of hospital contract review process, with reporting commencing from 2024/25.

Engagement programme to inform the development of the new Coventry and Warwickshire Palliative and End of Life Care Strategy completed by end of quarter 2 2023/24.

Palliative and End of Life Care Strategy published in January 2024.