The NHS Long Term Plan stated that all parts of England would be served by an Integrated Care System by April 2021 [1].

Integrated Care Systems (ICS’s) are partnerships between the organisations that provide health and care services across a local area. Services are coordinated in a way that improves population health and reduces inequalities between different groups.

Currently, all areas in England are covered by an ICS. There are 42 ICS’s accommodating for the entire population.

National Priorities

The introduction of Integrated Care Systems has meant that a new set of national priorities has been laid out. The intent is to build healthier communities, supporting people to stay well and independent at home, preventing avoidable admissions to hospitals and residential care [1].

The priorities are as follows:

Discharge to Assess: To fully implement the discharge to assess policy in each system in England

Modernise the Better Care Fund: To work together to improve people’s quality of life, by integrating health, housing and social care services  

Community Care: To prioritise urgent and community care services for older people, preventing hospital admissions

Transform Community Health Services: To baseline all expenditure, improving the digital infrastructure and updating the community services data set

Enhanced Health in Care Homes

“10.5 million people in ICS’s are over 65 years of age, 1.4 million people are over 85 years of age and 120,000 people are over 95 years of age”

People living in care homes should expect the same level of support as they would living in their own homes. With the introduction of ICS’s, this should be possible through collaborative working between health and social care, voluntary, community and social enterprise (VCSE) sector and care home partners [2].

Enhanced Health in Care Homes provides a framework for delivering health care to residents through the support of a multi-disciplinary team (MDT) including primary care, specialists, community-based care services and care home staff.

The Enhanced Health in Care Homes (EHCH) model moves away from traditional reactive models of care delivery towards proactive care that is centred on the needs of individual residents, their families and care home staff. Such care can only be achieved through a whole-system, collaborative approach.

Implementing this new framework ensures that:

  • People living in care homes have access to enhanced primary care and to specialist services that maintain independence, by reducing, delaying, or preventing the need for additional health and social care services
  • Staff working in care homes should feel at the heart of an integrated team that covers primary, community, mental health, and specialist care, as well as social care services and the voluntary sector
  • Budgets and incentives are aligned so that all parts of the system work together to improve people’s health and wellbeing
  • Health and social care services are commissioned in a coordinated manner, and the role of the social care provider market is properly understood by commissioners and providers across health and social care

Additionally, every care home should perform a weekly home round or check with residents based on the Multi-Disciplinary teams clinical judgement.

Residents should have personalised care and support plan within 7 days of re/admission to a care home. Structured Medication Reviews should also be in place for residents who would benefit from such a review.

Criteria for Success

The Framework for Enhanced Health in Care Homes published in March 2020 sets out the conditions that are critical for successful implementation [2].

Personalised Care:

  • Putting the needs of the person at the centre of everything through conversations and personalised care and support planning processes
  • Supporting people to talk about the outcomes that matter most to them; encouraging and enabling them to take as much personal responsibility as possible to manage their own care
  • Supporting carers and families in recognising their needs, as well as those of the individual care home resident, acknowledging them as experts in their own care


  • Working and integrating with local government, the community and independent care home sectors to co-design and co-deliver the model of care as equal partners
  • Acknowledging the value of the care home sector in working alongside the NHS and the level of healthcare that is delivered in care homes by social care staff
  • Adopting a whole system approach by breaking down the organisational barriers between health, social care and the voluntary, community and social enterprise sector


  • A focus on quality as the driving factor for change
  • Using clinical evidence to drive and sustain change


  • Leaders must have a shared vision for better care
  • Leaders should recognise the cultural differences between organisations, sectors and different types of commissioner and provider

Frimley ICS, East Berkshire

Frimley’s Multi-Disciplinary Team is GP led, they work on a weekly basis to visit care homes in the area. The team works with professionals such as the Matron Nurse Carer of a care home to discuss patients and their needs [3].

Meetings often result in changes to medication plans and these decisions are made through collaborative conversations between the lead GP, carers, nurses and care home coordinators.

Additionally, the Frimley multi-disciplinary plan involves implementing training within care homes to train staff on better practice to enhance resident care. Training involves courses on:

  • Reablement and rehabilitation services
  • Falls, strength and balance management
  • Oral care
  • Palliative and end-of-life care
  • Mental health support
  • Dementia care
  • Flu prevention and management
  • Leg and foot ulcer care

While many people living in care homes will be living with complex needs, including severe frailty, some may not. To deliver an effective Enhanced Health in Care Homes model, the needs of the entire care home population must be considered. Understanding the mix of needs in a care home, as well as the length of resident stays should determine the enhanced services and support needed.

[1] NHS. 2021. NHS achieves key Long Term Plan commitment to roll out integrated care systems across England

[2] NHS England and NHS Improvement. 2020. The Framework for Enhanced Health in Care Homes

[3] Hayter, Adrian. 2021. National Clinical Director for Older People and Integrated person-centred Care, NHS England

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The Enhanced Health in Care Homes Model sets out a plan for improving care in care homes using multi-disciplinary teams. This article outlines the methodology of the model and the criteria for success.

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