Award of Whole Systems Integrated Care (WSIC) Service in Brent to Brent GP Network Collaborative

About

NHS Shared Business Services awarded a contract to Brent GP Network Collaborative for the Whole Systems Integrated Care (WSIC) service in Brent, valued at £3,000,000.

The service supports the coordination and integration of care for adults with long-term conditions, with patients identified through GP registered lists and care organised around the GP-patient relationship.

The overarching objective is to keep vulnerable people well in the community.

The Brent GP Network Collaborative will undertake risk stratification and case finding from GP registered lists cross-referenced with partner caseloads; proactive care planning including goal setting, crisis planning, and review for patients most at risk, in need, or unstable; multidisciplinary case management with an enhanced mainstream care offer and more intensive case management for a subset of patients as required; support to self-care through administration and use of a new patient activation measure to tailor care plans and delivery, recruitment and piloting of Care Navigators to support patients and carers in accessing voluntary and community support in line with self-care goals and care plans, and staff training for GPs and colleagues in techniques such as Coaching for Health and Motivational Interviewing; development of multidisciplinary team working through alignment of team leaders from social care and district nursing and inclusion of mental health and voluntary and community sector representatives; weekly Complex Patient Management Groups (CPMG) hosted by each Network’s Core Team with participation of team leaders from Social Care and District Nursing; and monthly multidisciplinary group meetings.