Integrated Care | Boltons Health Matters
Skip to main content

Integrated Care

This indicator measures the average number of delayed transfers of care (for those aged 18 and over) that are attributable to adult social care, per 100,000 population. It is part of the Adult Social Care Outcomes Framework (ASCOF).

This indicator measures the average number of delayed transfers of care (for those aged 18 and over), per 100,000 population. It is part of the Adult Social Care Outcomes Framework (ASCOF).

The proportion of people aged 65 and over discharged from acute or community hospitals to their own home or to a residential or nursing care home or extra care housing for rehabilitation, with a clear intention that they will move on/back to their own home, who are at home or in extra care housing or an adult placement scheme setting 91 days after the date of their discharge from hospital. Part of the Adult Social Care Outcomes Framework.

Crossing professional boundaries: - a toolkit for collaborative teamwork has been developed by The King’s Fund with NHS Future Focused Finance. It is a simple seven-step process to enable cross-functional teams to reflect on how they work together, with a view to improving.

The Toolkit comes in 4 sections:

  1. An Introduction – what the toolkit is for and why should you use it
  2. Section A – why should you take the time as a team to reflect with your colleagues
  3. Section B – The Toolkit, and the 7-step process - Use this to strengthen joint working between clinical and finance teams
  4. Section C – Shortcuts, templates and suggestions

The Toolkit was refined following feedback and evaluation from the pilot phase, which involved NHS organisations across the country using the Toolkit with their own teams. An evaluation, carried out independently by the Chartered Institute of Public Finance & Accountancy (CIPFA), demonstrated encouraging outcomes in improving teamwork between clinical and finance teams, and consequently better outcomes for patients. Click here to read the evaluation.

- See more at:

The Better Care Fund is intended to transform local health and social care services so that they work together to provide better joined up care and support. This is the Better Care Fund plan for Bolton. Part 1 and Part 2 can be downloaded below.

AGMA (Association of Greater Manchester Authorities) have produced an overview of the current provision of integrated care in Greater Manchester (inclusive of current costs) as well as the potential benefits of the 'New Delivery Models'. This report includes: case for change; current state of and costs of provision; range and scope of change - both locally and nationally; delivery plan as well as a cost-benefit analysis of the potential changes.

This report is a must-read for all of those involved in the integrated care programme in Bolton.

An evidence summary produced by AQuA (Advancing Quality Alliance). AQuA is dedicated to improving healthcare across the NHS in the North West. Formed in recognition that improvement has to be led from the front-line rather than be centrally imposed, AQuA’s aim is to accelerate the pace of improvement and to help good practice to spread rapidly. Please visit and register with them here:

Key Points

  • Evidence relating to the theory of large scale reconfigurations and integrated care is plentiful, robust evidence of the impact at population (system) level is very limited.
  • To achieve the level of change that is required by political and economic imperatives, multi agency work for whole populations, such as the Total Place programme  seem essential. In the UK, The Kings Fund found insufficient evidence to assess and evaluate the outcomes of system integration. A ‘leap of faith’ is therefore required since large scale reconfigurations are known to take many years to demonstrate an impact.
  • Scale, pace and expert overall co-ordination is required to achieve major improvements in population health and well-being. Segmentation of the whole population, with targeted interventions for sub-populations / condition groups is recommended. There is UK evidence of service change having a major impact on health outcomes for condition specific high volume sub-populations, such as diabetes, trauma, stroke, mental health and older people. In older people’s care there is evidence of filtering of the many improvement initiatives that have been tried, and identification of the few that have a measurable impact.
  • Identifying and systematically addressing the enablers of system level reconfiguration is critical.
  • The role of the system level leadership and implementation team becomes one of orchestrating multiple service level reconfigurations, addressing the system enablers and ensuring that each sub population reconfiguration delivers the required results. Continuous evaluation as part of the overall system reconfiguration is essential to gauge progress against projected goals.

Evaluating Integrated and Community Based Care outlines the main community-based interventions that have been evaluated and their impact, and identify nine points that may help those designing, implementing and evaluating such interventions in future.

This publication provides a compilation of Accident and Emergency (A&E) data in England, to give a broad picture of the patient journey through A&E. This should be of interested in those commissioners involved in developing integrated care. The resource can be viewed by clicking here and selecting the resource you would like to download.


This is the product description and  of the 'Index of Potential Care Need' as part of the wider intergrated care project. The Index of Potential Care Need, classifies the older population of Bolton according to their risk of future early reliance upon intensive social care and support services.  The Index has been constructed by combining a range of risk factors known to be associated with early reliance on social care services such as living alone, having alcohol problems, and experiencing reduced daily activities and similar.  The aim of the Index is preventative and is designed to target people before they become too ill and/or dependent and need to access social care.

Share this: