North West London Whole Systems Integrated Care: a case study

Abstract

Introduction: North West London (NWL) has a population of over 2 million people and an annual health and social care spend of over £4bn. We have a diverse, growing and ageing population and need to make best use of resources in order to respond to changing needs. Change implemented: In 2013 partners from across the health and social care system began a journey towards Whole Systems Integrated Care (WSIC) that, when completed, will see us delivering new person-centred models of care, jointly commissioned and delivered across organisational boundaries. During the initial 8 month ‘co-design phase’ over 200 stakeholders from health, social care, service users and carers co-produced a framework - the Integrated Care Toolkit - for the delivery of integrated care in NWL. Following the publication of the Toolkit, 9 collaborative ‘Early Adopter’ partnerships began to translate the Toolkit into local delivery models, initially focussing people aged over 65. A number of these new service models have begun to go live in 2015. New models addressing the needs of further population groups will be implemented from 2016 onwards with the ambition of fully comprehensive coverage by 2018. Key findings: The Integration Toolkit, which is freely available on-line at http://integration.healthiernorthwestlondon.nhs.uk , has proved a useful starting point for the development of new models of care locally and has been viewed widely both nationally and internationally. Once local implementation got underway, the need for more detailed guidance about financial flows, governance and shared data became clear and a new set of handbooks were developed to provide specific support on operational, legal and delivery considerations and were consolidated into a ‘Toolbox’. An evaluation of the design phase was carried out by the Nuffield Trust and London School of Economics. Their report identified some of the themes below. Highlights: - The importance of co-design; building a common vision and framework grounded in the needs of the service user provides a strong foundation for transformation but takes time and can be challenging. The principle of co-design continues to be relevant passed the initial production of the framework however its role and focus needs to adapt and change. - Maintaining a balance between local and system-level focus; whilst there is clear value in working at scale to build momentum, reduce duplication and ensure consistency and stability at system level, there is a need to embed ownership locally to make changes relevant and sustainable - Integrated data is critical to integrated care; shared data is necessary for both the commissioning and delivery of effective person-centred integrated care. The multiplicity of systems and the information governance that underpins them has provided a considerable challenge. Developing the right capabilities and capacity in the system to utilise the data produced is a critical consideration as we move into implementation. - New ways of working; underpinning our programme are new models of care that require systemic behaviour change. We have developed a ‘Change Academy’ that brings teams together alongside service users to innovate new ways of working, break down organisational and professional barriers and ensure that the patient is at the centre of their care. - System-wide transformation takes time; the in-year ‘invest to save’ approach of most statutory change programmes does not take into account the time it takes to embed new models of care. Our initial timelines were ambitious and implementation has not happened as quickly as initially anticipated. The management of expectations with regards to timelines and benefits realisation is critical so that stakeholders (both local and national) do not become disillusioned with the ambitious work being undertaken. Conclusion: As one of 25 integrated care ‘Pioneers’ in England we are part of a community that shares challenges and the approaches being taken to address them. There is a striking commonality to the problems we face in implementing integrated care including; defining an organising principle for commissioning and delivering care; the operationalization of accurate and timely information sharing; the development of commissioning and contracting methodologies that embed joint accountability and the mainstreaming of new ways of working that bring teams of people together to meet the needs of the populations they serve. The ways in which we are addressing these challenges are not necessarily right or appropriate outside of NWL but they provide a case study for the design and delivery of integrated care at scale from which it is hoped there are lessons that may be valuable and applicable elsewhere.