The Continuing Journey to Integrated care in the Western Trust

“Pathfinder” developed in 2018 due to significant local service challenges in Fermanagh and West Tyrone. The population health needs assessment highlighted the importance of strong community and primary care services, and the support to informal and formal carers to meet the challenges of delivering safe and sustainable Health and Social Care services in rural geographies of NI. Fermanagh and West Tyrone has a population of approx. 128,000, a large area in NI in terms of land mass but sparsely populated with population density 38 people/km². Over 2,200 stakeholders attended 62 engagement sessions, patients, community and voluntary groups, carers, staff, schools, public representatives and other stakeholders to discuss future planning and delivery of services locally. Co-production was central, Experts by Experience (EBEs) interested in health matters in their area for very diverse reasons were recruited, to support, empower and ensure service users were empowered to be involved and promote joint responsibility for achieving positive outcomes. Engagement analysis coupled with population health data reflected a comprehensive picture of need and priorities for the Pathfinder area; in the report “Health and Social Care Needs of Fermanagh and West Tyrone, 2019”. This defined initial priorities for work. Participants included service leaders from the Western Trust and a wide range of external stakeholder groups and citizens. This discussion agreed to focus on five themes spanning the whole health and care landscape, but with a community based focus. It also highlighted the importance of workforce and transport as 2 further themes. Pathfinder drove much transformation and assisted in implementing of the Hospital at Home service; delivering interdisciplinary, integrated care in the community assessing and treating patients avoiding the need to attend ED or admission to hospital. At system level, Pathfinder through local intelligence formed new alliances, partnerships and collaborations enabling collective leadership; building on the foundations of coproduction, integration, quality improvement, research and data, in line with regional policy surrounding Integration Pathfinder places the West on strong foundations for the evolution of strategic planning and managing health and social care services based on specific population need. Applying this experience “Area wide” in the new ICS model as one of the key stakeholders presents huge opportunity.