Integrated Care Across Northamptonshire (iCAN) is a major new programme of transformation work being driven by NHCP.

Its purpose is to deliver a refreshed focus and way to improve the quality of care and achieve the best possible health and wellbeing outcomes for older people across our county, supporting them to maintain their independence and resilience for as long as possible. In line with NHCP’s vision for a positive lifetime of health, wellbeing and care in our community, the three core aims of the iCAN programme are to:

1) Ensure we choose well: no one is in hospital without a need to be there
2) Ensure people can stay well
3) Ensure people can live well: by staying at home if that is right for them

From our previous positive experiences of partnership working through NHCP, we know that it will only be possible to achieve these core aims and successfully deliver the iCAN programme by working closely together as a health and care system.

You can read a full introduction to the iCAN programme by visiting www.northamptonshirehcp.co.uk/iCAN.

We will also bring you regular updates from iCAN each month in Partnership Update, including focuses on the four key areas (or ‘pillars’) of iCAN activity: primary and community care, frailty, hospital discharge and a new operating model for Northamptonshire Adult Social Services.

Below, you can read more about the work of the frailty pillar while you can click here to read an update on the journey towards a new operating model of adult social care that’s already well under way.

Pillar Q&A: Frailty

What is this pillar focused on understanding?

The definition of ‘frailty’, the services and care pathways already in place, and any gaps, issues and opportunities for improvement.

Why is this pillar important to the programme?

Frailty is a set of circumstances, illness or conditions that can affect anyone. By having a specific focus on anyone aged 18 and over with a condition that makes them frail (e.g. limited mobility, limited mental agility, chronic illness, frequent attenders and anyone aged 65 and over) we want to ensure we have the right pathways in place to support people to access the right care in the right place, first time. Frailty spans all of the iCAN pillars, so our work will assist with other activity across the programme.

How does your pillar hope to support people to choose well, stay well and live well?

Our work will help to identify gaps in the patient pathway, bringing all relevant system organisations and services together to prevent deterioration of patients, provide the right care, treatment and support, and result in the best quality, experience and outcome for patients. We also want to give people the support they need to look after their own health and wellbeing.

What are the benefits of organisations / teams working together in a different way through iCAN?

Our work will link all current and future requirements together in a clear and flowing way to ensure we deliver the best outcomes for patients, organisations, targets and staff – putting patients at the centre of all we do.

What work is already happening to support the objectives of the pillar?

• Frailty management in care homes
• Development of frailty teams / assessment unit at acute hospitals
• Frailty assessment in the community
• Ambulance services role for frail people
• Better patient navigation to the right point of care, through an integrated care approach
• Underpinning principles, e.g. pathways, training and education, preventing patients deteriorating whilst in hospital, helping patient to remain at home, improving quality and safety, new ways of working and many more
• Reducing how long patients need to be in hospital

Within a very short time we have developed a system-wide team and plan to reduce the number of times some patients attend our hospital Emergency Departments (EDs). To be effective this needs to involve many services in a multi-disciplinary team meeting to discuss each patient and implement a care package that is tailored to the needs of each individual.

This will reduce avoidable ED attendances and admissions (particularly important through winter) and ensure these patients receive the care and support they need closer to home, helping them to enjoy a better quality of life. Work has already started to achieve this for some patients and this will be expanded over the coming weeks and months. All partner organisations and staff involved are really passionate about this work and doing their best for patients.

VIDEO: Dr Nicola Wilson, consultant in elderly medicine at Northampton General Hospital, talks more about the work of the iCAN frailty pillar.