How an octopus inspired integrated working

In Westminster, the octopus served as a model for creating an integrated neighbourhood team with its three hearts – local authority, health, and the voluntary, community and social enterprise (VCSE) sector – and eight tentacle roles reaching out into the community. Edward Ward, Octopus manager and operations manager (health inequalities) at GP federation, Healthcare Central London, explains more.

In Westminster, we are on a mission to tackle the complex societal problems that most affect health. And we are doing it through Octopus, an initiative that aims to unite local government, healthcare, and charitable sectors.

This ambitious project, which started about 18 months ago, seeks to address some of Westminster’s most pressing challenges. And there are plenty of them. We have the highest homeless population in Europe and there is an 18-year gap in life expectancy between its wealthiest and poorest residents. In the most deprived communities, employment opportunities are scarce, hope is low, and isolation is common. Adverse living conditions – such as high crime rates, drug use, and inadequate housing – severely impact health and wellbeing.

Alongside these challenges are difficulties in providing essential services to those most in need. The result is high A&E attendance and the exacerbation of untreated long-term conditions, affecting the individual and those close to them.

To address these intertwined issues, we have created Octopus, which covers 275,000 patients and is borough/ICB-wide.

Aims

Octopus – founded by Dr Saul Kaufman, who is senior responsible officer, with me (Edward Ward) as the operational lead – has the primary goals to reduce homelessness, prevent suicide, and decrease long-term unemployment. From a healthcare perspective, improved screening and routine care will help reduce the prevalence of vascular disease and cancer.

Why Octopus? Octopus serves as a fitting metaphor for our initiative, representing a multi-faceted entity with interconnected yet autonomous components working synergistically.

Originally named for its eight tentacles to represent roles such as social prescribers and care navigators, it has now evolved to reflect a more complex structure. At its core are three hearts: the local authority, health, and the voluntary, community and social enterprise (VCSE) sector. Each heart is vital for enhancing the health and wellbeing of the Westminster population. Informing these hearts is the brain, symbolised by research and academia, which drives innovation and strategic planning.

We aim for this to be the delivery vehicle for our integrated neighbourhood team (INT).

Method

We identify residents through the expertise of numerous professionals. This includes our expanding team of community health and wellbeing workers (CHWWs) who can uncover the ‘unknown unknowns’ by door-knocking in the borough’s most deprived areas. There are 25 whole-time equivalents at present and we hope to increase this to 100 with cross-organisational funding.

We also make use of various other roles within the Octopus INT, such as social prescribers, community matrons and family navigators. We are fortunate to be in a position where many of these community roles are funded by the Additional Roles Reimbursement Scheme (ARRS).

We are strengthening links between services hosted by different organisations. A CHWW can refer to a health and wellbeing coach and we are moving to a relational rather than transactional connection between staff. For example, a CHWW knows the name of the local health coach and can pass the patient on to a person rather than just sending an email to an unknown individual.

We pinpoint areas of need by employing population health management (PHM) techniques, along with identifying areas of highest need with the help of LSOA (Lower layer Super Output Areas) and local intelligence. This approach targets specific interventions, such as placing the CHWWs in the areas with the highest score on deprivation. This benefits the entire system by alleviating the burden on essential services, which have become the default resource for individuals with unmet needs.

Expansion

Patients can be seen in a variety of settings depending on need and the type of intervention. For example, CHWWs and health and wellbeing coaches can see residents in their homes, accompany them to appointments or meet them in the community to participate in social activities, such as painting workshops. It is about working around the patient to offer personalised care. 

As more partners join the Octopus initiative, we can expand where and when we see patients within the local area.

At present, our main partners are Westminster City Council, Central and North West London NHS Foundation Trust (CNWL), Central London Community Healthcare NHS Trust (CLCH), Imperial College Healthcare NHS Trust, The Abbey Centre, Paddington Development Trust, and One Westminster. We also have ties to London Zoo, Citizens Advice, and a number of smaller charities.

We have hosted six Octopus summits with around 100 attendees each time. Our only cost – aside from our time – is the venue, which is met by the GP federation, Healthcare Central London. However, further investment will be needed to reach the goals and objectives we have set for ourselves, which is to cover and impact the entirety of the borough.

Our current ambition is to hone in on the most deprived 25% of the population – i.e. 50,000 residents – providing them with CHWWs who will interact with around 120 households each per month.

Integration

One of the great benefits of this project is that it has fostered true integration, creating a sense of purpose and excitement as we undertake innovative work that can make a difference. We have generated momentum within the system, connecting with like-minded individuals and organisations that share our passion for real change.

However, there are also challenges. Collaborative work across multiple stakeholders requires significant time for meetings, discussions, and alignment on a common vision and goals. Organisations operate in different ways, each with their own set of priorities, which can sometimes clash with our vision for change.

Our monthly operation meetings, which include representatives from across health, the local authority, and VCSE, seek to unblock issues, float ideas, and provide updates on new initiatives. They are also a space for fostering relationships between individuals across organisations.

We are in phase two of the initiative, expanding buy-in from other organisations and setting up working groups. It is currently led by the GP federation, Healthcare Central London, and the ICB, though CNWL and CLCH are getting increasingly involved.

New and unique ways of quantitative data collection involving frontline staff allow us to identify issues and react with agility to the needs of the population. We are also gathering qualitative data from services within the Octopus, and we hope to compile these insights into a set of case studies. This will benefit wider audiences outside the borough who may also want to do things differently for their local population.

Future

This is a bold and transformative programme, aiming to integrate numerous partners within the Westminster landscape to build a cohesive community of residents and colleagues alike. In a short time, we have garnered excellent support and buy-in from both individuals and organisations. We hope to pool resources – utilising staff, expertise and knowledge from across the system – to avoid duplication and increase efficiency.

Working groups are in the process of being established, with representatives from across the borough coming together to help tackle specific issues, such as homelessness prevention, digital exclusion, suicide, housing and employment. The idea is that each working group will take on a particular issue with the relevant people from across organisations. It is yet to be seen if new services will develop as a result, but that is a definite possibility.

Looking ahead, the potential for this initiative is vast. To achieve our ultimate goals, we require further buy-in from both current and prospective partners in the form of resources, insights, and a willingness to embrace integration.

We hope phase three will involve funding from each organisation within the Octopus, strong links between services, and every part of the system included. However, this is a work in progress.

Ultimately, we aim to create a sustainable and impactful community network by fostering deeper integration and collaboration among partners.