The Demographic “time-bomb”

Cynon Valley Forum Top 4 Key Areas  Development of joined up services  Making Information available to professionals and users alike  Access to facilities especially transport  Equity of care within the locality especially Primary Care, Community care`and Social Care

Published 8 May 2009, doi: /bmj.b1484 Cite this as: BMJ 2009;338:b1484 Integrated care "New and better types of care cannot be delivered by housing different professionals under one roof or merging multiple organisations," said Niall Dickson, chief executive of the King’s Fund. "It requires bringing teams together, integrating the way staff work, and creating new relationships between organisations. US experience also suggests that integration is easier in organisations that are both commissioners and providers of care. Supportive leadership, strong local partnerships, and effective information technology and administrative systems are vital. significantly different practices existent in the organisations that are to be integrated; and the steep learning curve inherent in joining with another organisation. Longstanding power imbalances between acute and community care makes such integration a challenge."

HOSPITAL BASED CARE ASSESS DIRECT PRIMARY CARE OOH ORGANISED SYSTEM OF INTERGRATED COMMUNITY SERVICES PULL SHARED INFORMATION BASED ON GP RECORD Future System of Care “Seamless Pull System with Integrated Access to Information” Loc net Patient journey COMS HUB Resource team Primary Care Support Unit COMTMSCOMTMS Locality Networks to be created around natural communities building upon GP Practices and Community Health and Social Care Teams The core of the Community Resource Team will be built upon existing staff and services that currently outreach from secondary care and specialist social care teams and enhanced by salaried posts for GPs with specialist skills in managing patients in the community with complex needs alongside community-based Consultants who provide in-reach services to hospital beds. As a team they will support the locality teams to deliver care Community Rehabilitation ACAT Rapid response Teams Reablement Community Hospitals Case Managers CCM Paliative Care Community Based Specialists Admission/discharge Active rehabilitation Public health Prevention