Session one: Why integrated care matters
Chaired by Richard Humphries, Assistant Director, Policy, The King's Fund
Welcome and introduction
Simon Gillespie, CEO, British Heart Foundation
- Understanding integrated care
Professor Chris Ham, Chief Executive, The King's Fund
- Why it is important for Cardio Vascular Disease Services and what are the challenges for delivering integrated care for patients
Professor Huon Gray, National Director for Cardiac Care, NHS England
- A patient's perspective
Angela Camber, Patient representative, British Heart Foundation Council
Questions and discussion
Session two: How to make integrated care happen
Professor Peter Weissberg, Medical Director, British Heart Foundation
- Complex conditions: encouraging and supporting better integration of cardiac care and mental health
Hilary Walker, Head of Improvement Programmes and Clare Beard, Senior Improvement Manager, Preventing people from dying prematurely, NHS Improving Quality
- The House of Care: reorganising local services to provide better care and support
Dr Angela Coulter, Director of Global Initiatives, Foundation for Informed Medical Decision Making, Boston, and Visiting Senior Fellow, The King's Fund
- Improving care planning and support for self-management for people with long-term conditions (LTCs)
Dr Sue Roberts, Chair, Year of Care Partnerships
- Getting the vision right: a multi-disciplinary approach to providing integrated care for respiratory patients
Dr Noel Baxter, GP and Respiratory Champion, NHS Southwark Clinical Commissioning Group, and London Regional Lead for PCRS-UK
Dr Irem Patel, Integrated Consultant Respiratory Physician, King's Health Partners, Lambeth and Southwark Clinical Commissioning Groups
Questions and discussion
Buffet lunch, exhibition and networking
Session three: Case studies
Delegates were given the choice of attending one of the following workshops:
A. Supporting system wide integration: Southwark and Lambeth Integated Care Programme
Chaired by: Lara Sonola, Senior Researcher, Health Policy, The King's Fund
- Oliver Smith, Director of Strategy and Innovation, Guy's and St Thomas' Charity
- Liz McAndrew, Programme Director - Older People's Programme, Southwark & Lambeth Integrated Care
- Mark Kewley, Director of Strategy and Design, Southwark & Lambeth Integrated Care
B. Swansea BHF Heart Failure Project
Chaired by: Catherine Kelly, Director of Prevention and Care, British Heart Foundation
- Kathryn Roberts, BHF Heart Failure Co-ordinator, British Heart Foundation
- Beverley Mayer, BHF In-Patient Liaison Nurse, Morriston Hospital Tertiary Cardiac Centre
- Vanessa Morton, Advanced Pharmacy Practitioner, Abertawe Bro Morgannwg University Health Board
C. The Cardiovascular Outcomes Strategy in action: the Westminster MyAction Programme
Chaired by: Richard Humphries, Assistant Director, Policy, The King’s Fund
Presenters (all from MyAction Westminster programme, Imperial College HealthCare NHS Trust):
- Rhian Houghton, Specialist Cardiology Dietitian
- Tim Grove, Lead Exercise Specialist
- Judith Edwards, Lead Nurse
- Teresa MacKay, Team Lead
Session four: What have we learned?
Professor Huon Gray, National Director for Cardiac Care, NHS England
- Collaboratively working in Solihull to integrate services across health and social care for 'Jack and Eileen'
Dr Anand Chitnis GP, Chair, Solihull Clinical Commissioning Group
- Co-ordinated care for people with complex chronic conditions: key lessons and markers for success
Lara Sonola, Senior Researcher, Health Policy, The King's Fund
- An evaluation of the Integrated Care Pilot in North West London
Dr Geva Greenfield, Research Associate, Department of Primary Care and Public Health, School of Public Health, Imperial College London
The narrative for person centred and coordinated care: making it real
Jeremy Taylor, Chief Executive, National Voices
Questions and discussion
Simon Gillespie, CEO, British Heart Foundation
Assistant Director, Policy, The King's Fund
CEO, British Heart Foundation
Simon joined the British Heart Foundation in March 2013. Before joining the BHF, he was Chief Executive of the Multiple Sclerosis (MS) Society since 2006. Like far too many people in the UK, Simon has a personal connection with heart disease – his Father died of a heart attack in 1979. As part of the BHF's 'Fight for Every Heartbeat', Simon runs and walks to raise money for the BHF's work.
He previously worked as Head of Operations at the Healthcare Commission, where he was responsible for the inspection of NHS and independent healthcare facilities in England. From 2000 to 2004, he was Director of Operations at the Charity Commission, modernising the regulation and support of the 180,000 registered charities. His earlier career was with the Royal Navy, including time as Commanding Officer of HMS Sheffield and as an advisor to government ministers. Simon has extensive experience of charity and non-profit governance.
Professor Chris Ham
Chief Executive, The King's Fund
Professor Huon Gray
National Director for Cardiac Care, NHS England
Professor Gray has been a consultant adult and interventional cardiologist at Southampton University Hospital since 1989 and was Deputy NCD (2008-11) and then 'Interim' NCD (2012-13), at the Department of Health. Huon is a trustee of the American College of Cardiology and is a past president of the British Cardiovascular Society (2003-05).
Visiting Senior Fellow, The King's Fund
Dr Sue Roberts
Chair, Year of Care Partnerships
Sue Roberts is Chair of Year of Care Partnerships, having designed and been responsible for the successful delivery of the Year of Care Programme. She is a member of the RCGP Steering Group on care planning. She was previously National Clinical Director for Diabetes and for 30 years was a consultant physician, pioneering structured and integrated diabetes care and prevention programmes for cardiovascular disease across primary and specialist care in North Tyneside and Northumberland.
Dr Noel Baxter
Noel is a GP at Surrey Docks Health Centre in south east London and champion for improving and integrating respiratory services for the people of Southwark. He co-led the NHS London Respiratory Team from 2010 to 2013 and is currently a member of the London strategic network respiratory clinical leadership group. He is on the executive of the Primary Care Respiratory Society (PCRS-UK) and represents primary care for IMPRESS (Improving and Integrating Respiratory Services).
Dr Irem Patel
Integrated Consultant Respiratory Physician, King's Health Partners, Lambeth and Southwark Clinical Commissioning Groups
Irem Patel is a Consultant Respiratory Physician at King's Health Partners and Honorary Senior Lecturer at King's College London. She holds one of the first posts in Integrated Respiratory Care in the UK.
Dr Patel trained in London and undertook postgraduate research into mechanisms of COPD exacerbations at the London Chest Hospital. Her specialist and research interests include COPD, respiratory infection, respiratory failure and the development and delivery of pathways of care for patients with chronic respiratory disease. She leads a multidisciplinary specialist team spanning hospital and community delivering integrated respiratory care in south east London. She is COPD lead, oxygen lead and BTS stop smoking champion at King's College Hospital. She works closely with local Clinical Commissioning Groups to inform local respiratory strategy.
Dr Patel was the Clinical Lead for three NHS Improvement projects on service redesign for the implementation of the National COPD Clinical Strategy in 2010/11. She has worked as Clinical Adviser and member of the Steering Group for other NHS Improvement, National COPD and Asthma Improvement Projects. She is currently a member of the Steering Group for the Long Term Conditions work stream of Southwark and Lambeth Integrated Care.
On a London level, Dr Patel is a member of the London Clinical Respiratory Clinical Leadership Group and a member of the London Clinical Oxygen Network. On a national level she was involved in the development of competency frameworks to support the COPD Strategy and has served on the BTS Council and Education and Training Committees.
Dr Patel is Associate Editor of the Primary Care Respiratory Journal. She is actively involved in teaching and training both within King's Health Partners and in supporting respiratory skills and competencies amongst colleagues in primary care. She co-leads an annual "Respiratory medicine update for general practitioners" course at the National Heart and Lung Institute, Imperial College. This academic course aims to address common and difficult respiratory issues met in primary care and to offer practical solutions.
Senior Researcher, Health Policy, The King’s Fund
Professor Peter Weissberg
Medical Director, British Heart Foundation
Peter Weissberg graduated in Medicine from the University of Birmingham, UK in 1976. He trained as a clinical cardiologist before being appointed lecturer in Cardiovascular Medicine in the University of Birmingham. Following a two-year appointment as Medical Research Council Travelling Fellow to the Baker Medical Research Institute and Alfred Hospital in Melbourne, he was appointed to a British Heart Foundation Senior Research Fellowship at the University of Cambridge.
In 1994 he was appointed as the first British Heart Foundation Professor of Cardiovascular Medicine in the University of Cambridge. Professor Weissberg's research interests have focused on vascular biology and, in particular, the cell and molecular biology of vascular smooth muscle cells in atherosclerosis. His group has developed clinical imaging techniques to characterise atherosclerotic plaque composition in patients at risk of stroke. In December 2004 he became Medical Director of the British Heart Foundation, which currently distributes some £100 million annually for cardiovascular research, prevention and care in the UK.
Head of Improvement Programmes, Preventing people from dying prematurely, NHS Improving Quality
Hilary has been working in the improvement field for over six years, initially as a Cardiovascular and Stroke Network Director in London. Hilary was responsible for implementing a number of London-wide improvement programmes, such as the reorganisation of stroke services and the development of emergency arrhythmia centres for patients with heart rhythm problems.
Hilary has presented at many national conferences and has contributed to a number of papers evaluating services for stroke patients. Hilary has over 20 years' experience in the NHS working initially as a physiotherapist and latterly in a variety of general management roles up to Board Director level. She has a diploma in Physiotherapy and post graduate qualifications in health services management.
Senior Improvement Manager, Preventing people from dying prematurely, NHS Improving Quality
Dr Anand Chitnis
GP, Chair, Solihull Clinical Commissioning Group
Dr Anand Chitnis has worked as a GP since 1992 and is also a fellow of the Royal College of General Practitioners. He has a special interest in mental health, ENT and prescribing. He is a GP trainer and in the past has been a GP advisor to the National Institute for Mental Health in England (NIMHE) and the Care Services Improvement Partnership (CSIP). For eight years, Anand was the lead tutor/facilitator on the highly acclaimed Trailblazers course which ran throughout the UK and internationally. He has worked with the Solihull Care Trust on the PEC since 2006 and became PEC chair in 2008. He was elected chair of NHS Solihull CCG in January 2011 to take forward the development of the CCG out of the two locality PBC groups in Solihull which serves a population of about 240,000. Anand also chairs a registered charity for disabled children, The Newman Holiday Trust, which provides respite holidays to children and families from socially deprived communities. He studied medicine at St. Andrews and Manchester Universities, qualifying in 1987.
Dr Geva Greenfield
Research Associate and Deputy Director, Research Design Service Unit at Imperial College London (NIHR RDS London), Department of Primary Care and Public Health, School of Public Health, Imperial College London
Geva Greenfield has been a research associate at the Department of Primary Care and Public Health, School of Public Health, Imperial College London, since 2011. He is a social scientist (PhD, 2011), interested in the patient-physician relationship, health behaviour, health promotion, and health services research. He was previously involved in projects exploring adherence to clinical practice guidelines for primary and secondary prevention of chronic diseases; second opinion consultations (attitudes, behaviours, decision-making and policy).
During his PhD, Geva was a Fulbright Visiting Fellow at the Department of Anaesthesia and Critical Care, The University of Chicago Hospitals. He is experienced in mixed methods, including qualitative research methods and social science quantitative methods.
Geva was involved in the evaluation of the North West London Integrated Care Pilot and is currently developing further research projects dealing with the provision of integrated care and person-centred care.
UK Programme Director, Prevention & Care, British Heart Foundation
Catherine joined the British Heart Foundation (BHF) in July 2010 and leads on major initiatives including transforming the Healthcare Professionals programme, the introduction of commissioning support and user involvement. Her role involves leading teams delivering innovative projects, provision of information, support and guidance and CVD health and wellbeing in schools, workplaces and hard-to-reach communities.
Before joining the BHF, Catherine was a manager at the Multiple Sclerosis (MS) society delivering a new approach to service development and volunteer support. In her earlier work at the British Lung Foundation (BLF), as Head of Programme Development, Catherine established the BLF Specialist Nurse Programme and developed a patient self-management tool that was adopted across the UK.
Catherine is a member of the CVD Outcomes Strategy Implementation Group, PHE External Stakeholder Group and the Richmond Group. Catherine's early career as a nurse and manager provides invaluable experience in leading major change initiatives to improve service provision, patient experience and deliver economies of scale.
Director of Strategy and Innovation, Guy's and St. Thomas' Charity
Oliver joined Guy's and St. Thomas' Charity in November 2010 in the newly created role of Director of Strategy and Innovation and is responsible for the design and implementation of the charity's strategy. He works closely with the charity's partners to develop and deliver programmes that will improve health and healthcare for the local population and service users.
He was the head of the government's tobacco control team at the beginning of 2009 and focused on successfully taking new tobacco legislation through Parliament, and the development of the previous Government's tobacco control strategy "A Smokefree Future". Under the last government, he also worked in the Cross-Government Obesity Unit, where he led the writing of the strategy Healthy Weight, Healthy Lives, and was a Strategy Adviser in the Department of Health's Strategy Unit, where his work included the development of health reform and the Department’s efficiency programme within the 2007 Comprehensive Spending Review.
Prior to working in the Department of Health, Oliver was a Policy Adviser within the Prime Minister's Strategy Unit, involved in projects on energy, policing, and housing amongst many others. He has also worked as a consultant for OC&C Strategy Consultants.
Specialist Cardiology Dietitian, MyAction Westminster programme, Imperial College HealthCare NHS Trust
Rhian is employed by Imperial College HealthCare NHS Trust as a Specialist Cardiology Dietitian for the MyAction Westminster programme, which is a family based preventive and rehabilitation programme for vascular health. Rhian has a keen interest in Obesity and Weight Management running many Weight Management Groups and healthy lifestyle programmes for both adults and children throughout her career. Most recently Rhian has successfully set a Weight Management Programme within MyAction programme and presented a poster of the results at the BACPR conference.
Rhian has worked in the area of Nutrition and Dietetics since 2002 as a Registered Public Health Nutritionist and then qualified as a Dietitian in 2008. Rhian enjoys health promotion and teaching and has worked in both the NHS Community setting and within schools as part of Healthy Schools Teams in Tower Hamlets and Hackney. Rhian has experience of lecturing on diet and cardiovascular disease at Imperial College London and London Metropolitan University.
Lead Exercise Specialist, MyAction Westminster programme, Imperial College HealthCare NHS Trust
Tim is employed by Imperial College HealthCare NHS Trust as the Lead Exercise Specialist for the MyAction Westminster programme, which is a family-based preventive and rehabilitation programme for vascular health. Tim is also a Senior Teaching Fellow in Physical Activity and Exercise on the Master's, Postgraduate Diploma, Postgraduate Certificate and Short Course programmes in Preventive Cardiology at Imperial College London.
Tim first qualified as a BACPR Exercise Instructor in 2000 and his previous work has involved running phase IV exercise classes and co-ordinating the exercise component of Heatherwood and Wexham Park hospitals Phase III cardiac rehabilitation programme. Tim graduated in 2007 with a Master's degree in Cardiovascular Rehabilitation from the University of Chester and he has also published in peer reviewed journals, contributed towards the national standards on physical activity and exercise in cardiac rehabilitation and written book chapters in cardiovascular prevention and rehabilitation. In addition, Tim has also presented research at the Royal Society of Medicine Sports Medicine Conference and at the British Association for Cardiovascular Prevention and Rehabilitation's conferences.
Team Lead, MyAction Westminster programme, Imperial College HealthCare NHS Trust
Teresa qualified as a nurse in 1991 and has worked within the field of cardiology for the last 23 years. She has worked in CCU's and ICU's in both the United Kingdom and Australia. Teresa assisted in the development of the cardiac rehabilitation service for Bexley in 2005-2009. During this time she developed an interest in primary prevention as well as secondary prevention this was further inspired by the development of the MyAction programme. Teresa followed the pilot programme with keen interest and joined the MyAction programme at Westminster in 2010.
Teresa is the team lead for the MyAction programme and is responsible for ensuring that the programme delivers high quality services to its users. She co-ordinates the multi disciplinary team in the acute setting as well as in the community. She manages a clinical caseload and is a nurse prescriber.
Lead Nurse, MyAction Westminster programme, Imperial College HealthCare NHS Trust
Judith joined Imperial Healthcare in 2007 as the Senior Cardiology Nurse Specialist for the Cardiac Prevention & Rehabilitation Service and in 2013 she also became the lead for the Westminster MyAction Cardiovascular Prevention & Rehabilitation Programme. Prior to this Judith worked as a community cardiac nurse specialist for a PCT where she set up cardiac services including CR programmes in the community.
In the 1990s Judith was successful in gaining funding from the British Heart Foundation to set up one of the first community cardiac service for Heart Failure patients in this country. Judith has published in peer reviewed journals and has presented oral and poster presentations at national and local events on cardiac prevention & rehabilitation. She has been the nurse lead for the North West London Cardiac Rehabilitation Network and as secretary of the BACPR was part of the steering group for the development of the national guidelines for CR.
BHF Community Heart Failure Co-ordinator,
Abertawe Bro Morgannwg University Health Board
Kathryn Roberts is leading the British Heart Foundation funded Heart Failure Project in Swansea, working as the Community Coordinator since March 2013, employed by Abertawe Bro Morgannwg University Health Board. In this role she coordinates the new Heart Failure Service across care sectors. She qualified as a Registered General Nurse in 1991, and gained a BSc (Hons) degree in Nursing (including a teaching award) at Swansea University in 1995. She specialised in Cardiology, having worked in the Coronary Care Unit at Morriston Hospital Tertiary Cardiac Centre, Swansea, for many years & in the community as part of the Swansea Cardiac Rehabilitation Team.
In 2006, she further specialised in Heart Failure care moving to a BHF funded post in the Neath Port Talbot area, where she set up a nurse led service, & embarked upon up skilling Primary Care Professionals. She is an Independent Nurse Prescriber (2006, Swansea University), & holds a Specialist Cardiac Diploma (Cardiff University), Caledonian Heart Failure Diploma (University of Leicester) & Post Graduate Diploma in Clinical Leadership (University of Glamorgan).
BHF Community Heart Failure In-Patient Liasison Nurse, Abertawe Bro Morgannwg University Health Board
Beverley Mayer qualified as a Registered General Nurse in 1988. She has worked as the British Heart Foundation funded Heart Failure In-Patient Liaison Nurse, Abertawe Bro Morgannwg University Health Board, since July 2013. She is based at Morriston Hospital Tertiary Cardiac Centre, Swansea. This is a new post developed as part of the new heart Failure pathway. Beverley has an extensive cardiac background, having twenty four years experience working in acute cardiology, as a senior sister. During part of this time she also co-ordinated the cardiac rehabilitation programme.
She has also led on numerous ‘in-house’ teaching programmes. Beverley possesses the (WNB) Cardiac Course 254 from the University Hospital of Wales (1991), & BSc (Hons) in Nursing (including a teaching award), Swansea University (1993). She has gained a heart failure diploma & degree level qualification.
Advanced Pharmacy Practitioner, Abertawe Bro Morgannwg University Health Board.
Vanessa Morton qualified as a Pharmacist in 1998 & gained a Masters Degree in Clinical Pharmacy in 2001 at Cardiff University. Initially she gained experience working in the commercial sector. She gained employment as a Prescribing Advisor serving the Swansea Locality in 2001. Since then she has gained an Independent Prescribing qualification at Swansea University in 2005. She also holds an Anticoagulation diploma (Birmingham University) and Heart Failure Degree level qualification, enabling her role working in the community based Warfarin Service and Heart Failure Service as well as her prescribing advisory function in the Primary Care setting. She is currently working closely with the BHF funded Swansea Heart Failure Project Team, and is currently working as an Advanced Pharmacy Practitioner, Abertawe Bro Morgannwg University Health Board.
Director of Strategy and Design, Southwark and Lambeth Integrated Care
Mark is the Director of Strategy and Design at Southwark and Lambeth Integrated Care. In his role Mark works to support the SLIC Sponsor Board (a coalition of leaders from commissioners, providers and citizens) to develop a practical plan to improve how people experience care. In particular Mark oversees work on how the CCGs and local authorities can develop a joint approach to commissioning for population outcomes, and how care providers can work together to handle new funding arrangements and develop new models of care delivery.
Mark joined SLIC having previously been the Strategy Lead at an acute hospital foundation trust based in London. Before joining the NHS Mark worked as a Senior Policy Analyst for health within the No.10 Policy Unit, and as a lead advisor on public service reform within the Cabinet Office Strategy Unit.
Programme Director, Southwark and Lambeth Integrated Care
Liz is a Programme Director at Southwark and Lambeth Integrated Care. In her role Liz is responsible for delivering the Older People’s Programme and she leads a change team whose role it is to design, test and evaluate new models of care for all over 65s in Southwark and Lambeth.
Liz has more than 10 years experience working in public services in operational leadership and clinical roles, working to transform services to achieve better patient experiences, better outcomes and better value. Before joining SLIC, Liz held senior operational roles as General Manager for Acute and Emergency Medicine, both at Guy’s and St Thomas’ NHS Foundation Trust and prior to that, at Barts Health NHS Trust. Liz started her career as a Physiotherapist and is passionate about transforming services and the role that testing can play in radically changing the way that services are delivered.