Evaluating a whole systems approach to

integrated care in North West London

Nuffield Trust & London School of Economics

22 June 2015

Holly Holder (holly.holder@nuffieldtrust.org.uk)

Project team: Matthew Gaskins, Holly Holder, Judith Smith and Gerald Wistow

Presentation structure

1. Methodological challenges

2. What is the Whole Systems Integrated Care programme?

3. Our methods

4. My reflections

Methodological challenges

• How do you evaluate such a large and complex programme?

• In such a multi-level programme, which level do you investigate?

• How do you evaluate something that is constantly changing?

What is the Whole Systems Integrated Care (WSIC)

programme vision?

Vision

• Care is coordinated around the individual

• Care is provided in the most appropriate setting

• Funding flows to where it is needed

Aims

• People will report a better quality of life

• Quality of care will improve

• Better care will be delivered at lower cost

• Providers will operate more effectively

• Professional experience will improve

WSIC process and delivery

• Develop accountable care partnerships (ACPs)

• Use a capitation payment model that incentivises providers to work together and focus on population outcomes rather than activity

• To have GPs at the centre of organising and coordinating care within the ACPs

• To make patients equal partners in all aspects of design

North West London

• 2 million population

• 8 local boroughs

• 8 clinical commissioning groups

• £4+ billion annual health and

social care spend

A complex provider landscape

Mount Vernon

Harefield

RNOH

Hillingdon

Northwick Park

Ealing

West Middlesex

Central Middlesex

Hammersmith

Charing Cross

St Mary’s

Chelsea and Westminster

Royal Brompton

Royal Marsden

Imperial

London

North West

Western Eye

St Charles

• 10 acute and specialist

hospital trusts

• 2 mental health trusts

• 2 community health

trusts

• 400+ GP practices

Which organisations are involved in WSIC?

Source: WSIC Integrated Care Toolkit

How is the WSIC programme funded?

• Top-slice of 2.5% of pooled budgets of eight NW London CCGs and NHSE commissioning budget for NW London

• Programme management team also drives other, related initiatives: acute hospital reconfiguration, and programmes to reform primary care and mental health services

• Additionally, all eight NW London CCGs have joined to work as a collaborative

Two levels of operation: pan-NWL level

Adapted from WSIC Integrated Care Toolkit

Governance structures

Activities at a pan-NWL level

Tackling the ‘tough nuts’ once at the pan-NW London level...

Source: WSIC Integrated Care Toolkit

Two levels of operation: local level (Early Adopters)

3

Summary of Early Adopters: What we are trying to do

Brent▪ MCP model for people over the

age of 65 with one or more long-term conditions

▪ MCP would be an accountable partnership of primary, community, acute and local authority care providers, led by a GP Network

Tri-borough (Central London, H&F, West London and Community Independence Service)▪ 3 MCP models (early adopters local to each borough) and a PACS

model in the form of the CIS▪ Provides opportunity to test proactive early adopter model aiming

to keep people well , building on strong voluntary sector provision of self-care support, alongside more reactive CIS support aimed at keeping people out of hospital or getting people home quicker after crisis

Hounslow▪ MCP model for people aged 16 and

over with one or more long term condition and people with dementia

▪ Model based on multi-disciplinary working, care coordination, self-management and care planning

Harrow▪ MCP model for people over the age

of 65 with one or more long-term conditions

▪ Enhancement of primary care with an expanded range of health professionals such as senior nurses and hospital specialists

Hillingdon▪ PACS model for people over the age

of 65 with one or more long-term conditions

▪ Services wrapped around the person to ensure that they receive the right care at the right place at the right time

▪ Third sector to community based support promoting independence and self-care and reducing social isolation

Ealing▪ MCP model for individuals over

75 with one or more Long Term Conditions

▪ Model based on joint care teams in all localities, care coordinators and navigators, multi-professional care planning, and self-care

Source: North West London Five Year Forward View Vanguard bid

The process happening at the local level

WSIC’s ten-step methodology for developing whole systems integrated care

Source: WSIC Integrated Care Toolkit

Our research questions

We explored:

• The way in which the WSIC programme is being designed

• Its involvement of local stakeholders in the processes of design

• The development and early implementation of early adopter schemes

• The extent to which the WSIC programme appears to be on track towards its objectives.

Our approach: pan-NWL level

• Formative evaluation

• Regular meetings with programme team

• Workshops with Early Adopters and programme team

• Focus group with Early Adopters

• Evaluation steering committee

• Interviews with senior stakeholders (~88)

• Observations of programme team meetings (120 hours)

• Survey of GPs in NWL (39% response rate, n=160)

Our approach: local level

• Four case study Early Adopters

• Interviews with key individuals

• Observations of Steering Committee meetings

• Survey with all Steering Committee members (60% response rate, n=109)

• Workshops with representatives from all Early Adopters

How do you evaluate such a large and complex programme?

• Combine breadth and depth

• In-depth interviews with limited number of people

• Workshops and focus groups

• Survey with all Steering Committee members

• Purpose: thoughts on progress, challenges, achievements

• Survey with GPs in NWL

• Purpose: contextual information to explore how easy or difficult it

was going to be to roll out the programme

• ‘What would help you to deliver more integrated care?’

• ‘Have you heard about the programme?’

• Observations and document reviews (governance papers)

• Does what people say match what is actually happening?

In such a multi-level programme, which level do you

investigate?

• Identify where change is taking place (in integrated care projects – macro, meso, micro)

• Monitoring of pan-NWL issues (context: financial, provider landscape, commissioning; developments and progress with programme team)

• Monitoring of all Early Adopters

• Case study approach for in-depth exploration of change at the Early Adopter level

In such a multi-level programme, which level do you

investigate? (2)

How we selected the case studies:

• Where is the early adopter based?

• Geography, complexity of health economy, contextual

differences.

• Who is involved in the early adopter?

• Target population characteristics, partners delivering the

intervention, readiness for implementation.

• How will the early adopter be delivered?

• Scale of initiative in terms of quantity, scale of initiative in

terms of quality, extent of social care involvement.

How do you evaluate something that is constantly

changing?

• Benefits of a formative evaluation

• Benefits of a realist evaluation approach

• Interviews/surveys at different time points

• Repeat interviews with same individual

• Develop a key contact within the programme team

• Board minutes are an excellent resource

• Keep up to date with local and national developments

Methodological challenges

• How do you evaluate such a large and complex programme?

• Take advantage of different methodologies

• Observations

• In such a multi-level programme, which level do you investigate?

• Both organisational and local

• How do you evaluate something that is constantly changing?

• Timing of research

• Approach to evaluation

• Regular contact

• Tracking national and local policy context

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