Coordinating care: whose responsibility is it?

What do residents want from health and social care providers?

What do residents want from health and social care providers? One CCG in Greater London finds out

Picture: iStock

There is little doubt that every area is facing unprecedented pressure on their health and social care budgets, and rising demand for services given the demographic of an ageing population.

In 2015 Kingston Clinical Commissioning Group (CCG) health and social care commissioners decided that the best course of action to take, in respect of these pressures, was to ask local residents what they wanted from their health and social care services. The residents said:

  • They wanted to be understood by the people working with them.
  • They wanted to be involved in planning their own care and support.
  • When the care and support was agreed, could it then be delivered to plan as promised.

It was clear to commissioners that, at face value at least, everything that had been commissioned up to now appeared far more complex than was necessary.

Kingston CCG needed a completely new way of working. So, the commissioners created Kingston Coordinated Care (KCC).

Kingston Coordinated Care workforce

The Kingston Coordinated Care six partner workforce consists of:

  • Kingston Hospital NHS Foundation Trust
  • The Royal Borough of Kingston upon Thames
  • Kingston GP Chambers
  • South West London and St George’s Mental Health Foundation Trust
  • Staywell charity
  • Your Healthcare CIC

KCC was designed to deliver better services and improved outcomes for the people of Kingston, through the development of a more integrated service offer from care providers.

The KCC objectives are:

  • To ensure people stay independent, healthy and well for longer with good community support so they can enjoy their lives to the full.
  • To ensure people have easy access to top quality, person-centred, coordinated health and social care support when they need it.

This group of people, known as the design team worked with their colleagues to design KCC.

The group was made up of a therapist, nurses, psychiatrist, GP, voluntary sector lead, social care manager and a domiciliary service manager and they were generously funded to allow for backfill by the commissioners. The work they undertook is illustrated in Pat’s case.

Pat was a 70-year-old woman who fell in the street. Although she requested to return to her home, which she could see from the spot where she fell, she was taken to the local hospital, Kingston Hospital NHS Foundation Trust. After 47 interventions and a three-day stay, Pat returned home. She had sustained no injuries and was perfectly well.

The design team worked with Pat to justify a reason for each of these interventions. They determined that five of the interventions had a value. The intervention that Pat most valued was going home.

It highlighted for the design team just how much time and resource was eaten up with unnecessary tasks and tests and how little Pat’s voice was heard. From this, the team developed a set of golden principles.

Golden Principles of Kingston Coordinated Care

  • We try to understand you as completely as possible, as early as possible
  • We have good quality, timely shareable information about you
  • We limit the number of times we ask you for and share your information
  • We work with you to achieve the best shared decision at the best time by the best possible person and team
  • As a person using services, you know what is going to happen next and who to ask
  • We keep listening to what you say to us
  • We work with you, your relatives and carers to the best of our ability


The shifting national context has seen the focus change to integrated care systems and partnerships. Previously the focus was on commercial behaviours resulting from drivers such as separate public sector budget allocations and payment by results funding mechanisms.

The intention is that different organisations from the health and care systems work collaboratively to improve the health and well-being of their local population, by integrating their service delivery.

KCC has been actively assessing, signposting and referring people to the right care, at the right time, in the right setting for some time now. Kingston CCG have new community connectors – a social prescriber role facilitating social activities in the community – in place to promote this.

To date, health and social care services have typically been measured by their processes, for example, number of individuals using a service, or the number of staff involved in service delivery. Shifting the focus to measuring the impact of the system on a population’s health (using outcomes) provides a shared purpose for all organisations to strive towards, and therefore incentivises partnership working and an increased focus on prevention.

Focusing on outcomes in addition to financial and process measures will provide a holistic view of the health economy.

In 2017/2018 Your Healthcare saw more than 32,000 through the KCC approach.

Moving forward

This community focused, maximum effort, multi-organisational approach is, to my mind, the panacea for effective delivery of health and social care.

It will have a substantial impact on practise because it demands using professional knowledge in a way that supports the individual to meet their wellness goals as they describe them – not as the various professionals define them.

Siobhan Clarke is managing director of Your Healthcare

Siobhan would like to thank everyone in Kingston connected with the KCC programme for their commitment and resolve in seeing this work come to fruition.

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