Pioneering Whole Systems
Integrated Care
A view from North West London
Caroline Bailey – Assistant Director, NWL Collaboration of CCGs
John Norton – Lay Partner, Embedding Partnerships
Stephen Day – Director of Adults Services, London Borough of Ealing
NCAS – 29 October 2014
Living longer
and living well
Whole System Integrated Care
North West London covers two million people and has committed to an ambitious
out of hospital strategy
North West London
2 million
people
8 local
boroughs
8 CCGs
Over £4bn
annual
health and
care spend
Over 400 GP practices
10 acute and specialist hospital trusts
2 mental health trusts
2 community health trusts
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Now Whole Systems Integrated Care is integral to our plans for transformation
Our shared vision of the WSIC programme …
“
… supported by 3 key principles
We want to improve the
quality of care for
1
People will be empowered to
direct their care and support
and to receive the care they
need in their homes or local
community.
2
GPs will be at the centre of
organising and coordinating
people’s care.
3
Our systems will enable and
not hinder the provision of
integrated care.
individuals, carers and
families,
empowering and
supporting people to
maintain independence
and to lead full lives
as active participants in
their community
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and living well
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We developed a framework to guide us through answering the difficult questions
Scope
Which groups
of people
should we
organise care
around?
What goals do
people in those
groups want to
achieve
Commissioning
Provider
Funding
mechanism
What services could
providers provide
better if they work
together?
How do we bring
existing resource
together to deliver the
goals that matter?
How do different
providers of care
decide to spend
money in new ways?
Investment and
risk is shared
through
capitated
budgets
Capitation
allocation used
by providers to
cover all service
user care
Outcomes:
People empowered to direct their
care and support and to receive the
care they need in their homes or local
community
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Pioneer status gave us the momentum and mandate to bring partners across the
system together and help answer those questions
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Lay partners…
… bring courage and encouragement
… are whole life assets
… push for blue sky thinking
… hold projects to account
… maintain a health tension between
delivery and co-design
… bring patients to the centre
… embed insights and expertise from
different backgrounds
… influence and challenge language
and behaviour
Lay Partners are “guardians of the vision”
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Lay partners are now defining the outcomes that WSIC models of care need to
achieve and how they should achieve them
“ Service users and carers
must be able to trust
the system ”
“ Users and carers are
empowered,
“ There is full continuity
of care for service
users via named
people ”
supported and can
access appropriate
education ”
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“ A common, simple
language is used ”
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We have put the content from the co-design phase into a ‘Whole Systems Toolkit’
integration.healthiernorthwestlondon.nhs.uk
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Across NWL ‘Early Adopters’ consisting of commissioners and providers are
planning the implementation of Whole Systems Integrated Care
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Whole Systems Integration journey in Ealing
2015/16
2012/14
2014/15
Pioneer Status:
Integrated
Care Pilot
79 GP’s grouped into
7 Multidisciplinary
Groups (social
workers, community
health, acute)
High risk cases
assessed monthly
across all networks
through Care Planning
Vision, Principles & Approach across
NW London
Better Care Fund requirements
Integration
Programme
Mobilisation
• ONE
INTEGRATED
PLAN to deliver
•
•
•
Key features of our
Integrated care model
•
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Embedding Partnerships/Patient and Public engagement
Commissioning governance & finance
Population and Outcomes / Care coordination & navigation
Provider and GP networks
Information
change (including
outline plan for 75+
with LTCs)
Begin
implementation of
agreed schemes /
prototypes
Creation of Joint
management team
(LA/CCG)
Joint Programme
Management Office
Evaluation of
prototypes
Integration
Programme
Implementation
• Model of Care
revised following
evaluation
• Healthy at Home
Scheme starts
(Funded by BCF)
• Identification of
virtual capitated
budget
• Options for an
Accountable Care
Partnership
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Ealing Model of Care
• Aligning nursing and
social work team
structures to GP
localities
• Target population
group - the over 75s
with one or more
long term health
condition
• Teams supported
by care
coordinators and
care navigators
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Healthy at Home: working towards a new configuration of intermediate care
services
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Questions
?
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