Integrated care and related themes

Healthwatch Hackney wanted to understand people's needs for integrated care.  They used existing research to identify people's needs

Integrated Care Overview

Key issues in integrated care include unclear definitions, the need for a more holistic (social rather than purely medical) approach, and better monitoring of services. Core priorities identified were:

• Stronger partnerships with service users, carers, and the voluntary sector
• Clear accountability
• Adequate staffing and supportive care
• Better information and signposting
• Improved coordination and faster access
• Equal access and greater patient choice

Key Areas of Care

1. Frail Elderly & Complex Needs
Older people, especially over 75, are highly vulnerable and often have multiple conditions. Priorities include coordinated services, continuity of care, effective discharge, and staff training. Many rely on informal care, while some lack access to needed support. Key actions should include:

• Holistic, comprehensive care plans
• Involvement of carers
• Safe discharge and reduced readmissions
• Appropriate emergency care and transport

2. End-of-Life Care
Patients want informed choice and control over their care, alongside support to address social isolation.

3. Preventative Care
Prevention is essential, including addressing wider factors like housing and isolation—often as important to patients as medical care.

4. Financial Support
Patients report insufficient financial support, particularly at discharge, and need help with payments and budgeting systems.

5. Mental Health Care
Mental health support should be fully integrated with other services. Issues include poor coordination, lack of understanding, weak community support, and problems with medication and discharge. More early-stage support is needed, including for families.

Cross-Cutting Themes

• Communication: Poor communication and long referral times are common issues; patients want clearer, accessible information.
• Continuity of Care: Patients value consistent professionals and accurate record-keeping.
• Individual Needs: Services should adapt to individual requirements, including learning disabilities.
• Cultural Sensitivity: Diverse communities require culturally aware care; gaps exist in interpretation and understanding.

Carers

• Informal Carers: Play a vital role but lack recognition, support, and clear information; a named contact would help.
• Care Workers: Concerns include quality of care, staff turnover, and difficulty raising complaints.