The traditional clinical model of care for older people is too often disjointed and unable to meet people’s needs holistically. How can we radically reorganise care to help more older people stay healthier for longer within the health and care system?

My Care My Way is a new way of working with people aged 65 and over in West London. It brings together physical and mental health, social care, and the voluntary sector services to plan and deliver care to patients that meet their holistic needs. There is a multidisciplinary team located within a GP practice that delivers the service.

Our team at Innovation Unit conducted learning lab sessions, a safe space for GPs, My Care My Way staff and practice colleagues to reflect on the challenges of delivering the service and identify opportunities for improvement.

Journey

We developed a bespoke diagnostic tool to deliver these sessions in a practical, open, engaging way across all GP practices. The tool and our method were intended to bring out collective insights about how the team was performing with each of the service principles from the perspectives of front-line staff experiences and patient feedback.

Encouraging self-reflection before each session:

• Sending online surveys to gather anonymous, individual thoughts first to encourage honest feedback

• Collecting the feedback, marking them on the tool before a session, and adding a layer of quantitative performance data to provide context

Facilitating group reflection sessions using the diagnostic tool:

• Reviewing both qualitative and quantitative data

• Finding gaps and reflecting on the team’s strengths and weaknesses in embedding the service in an existing GP practice

• Identifying areas of focus and planning the following actions around what can be done differently to work well together as a team

• Identifying system-wide changes to deliver the service to a high standard