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Inner North West London Integrated Care Pilot – year one evaluation

8 July 2013

Holly HolderFellow in health policy

Ian BluntSenior Research Analyst

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What is the inner North West London Integrated Care Pilot?

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Aims of the pilot

Large-scale programme to improve the coordination of care for people over 75 years of age and/or adults living with diabetes.

Aims:

•Improve outcomes for patients

•Create access to better, more integrated care outside hospital

•Reduce unnecessary hospital admissions

•Enable effective working of professionals across provider boundaries

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Setting up the pilot

Started in July 2011

Initial £10m investment from NHS London

Involved organisations:

• Five local authorities

• Three acute hospitals

• Two community hospitals

• 104 general practices

• Representatives from Age UK and Diabetes UK

Area covers 550k patients

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At the local level – multi-disciplinary groups

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Our evaluation

Evaluation of the first year active Sept 2011 – July 2012

Four strands of research, in partnership with Imperial College Department of Primary Care and Public Health

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Key findings on

Strategic implementation & context

and

Patient & professional experience

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Qualitative data collection

Data collection methods Number completed

Semi-structured interviews with senior leaders of the pilot &

participating organisations and other health policy experts

37

Focus groups with healthcare professionals and managers 4

Survey of healthcare professionals 51 completed in full (25.5% response

rate)

Survey of service users enrolled in the pilot 405 completed in full (20.25% response

rate)

Observation of IMB meetings and meetings of its committees 30 hours

Observation of MDG meetings (of which ten hours were

transcribed, coded and analysed in detail)

20 hours

Semi-structured interviews with GPs about the influence of the

ICP on diagnosis rates

Seven general practices

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Strategic implementation

What worked well?

•Successful engagement of organisations from across health and social care, assisted by a clear vision of aims

•Sophisticated governance structures critical for engagement of organisations

•Financial incentives important for bringing people on board

Challenges

•Balancing local autonomy with overall accountability

•Symbolic financial incentives

•Achieving more direct engagement of service users

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Patient and professional experience

What worked well?

•Health professionals had a high level of commitment to the pilot, in particular the care planning process

•Care planning and Multi Disciplinary Groups improved collaboration and levels of professional knowledge

Challenges

•Majority of patients had not experienced any changes

•Care planning IT tool led to dissatisfaction amongst many practitioners. Over half of professionals felt workloads had increased

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Impacts on service use and cost - evaluation using predictive risk techniques

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Quantitative data collection and three-armed approach

The general population of inner North West London and the pilot’s target population:

•Observed activity using administrative data sets

•Contrasted to other areas of London and nationally

A fixed cohort of patients who had received a care plan compared to individuals with similar population characteristics:

•Observed changes associated with ‘usual care’

•Matched control group identified by: predictive risk score for emergency hospital admission, age, sex, prior hospital utilisation, health conditions etc

Patients with care plan by

end 2011 (1,494)

Patients eligible for ICP

(35,607)

All patients in ICP

practices (502,920)

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Emergency admissions for ‘ICP eligible’ patients

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Distinct emergency admission patterns by financial year in the main provider

FY 2009/10FY 2010/11

FY 2011/12

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Analysis at person level

Months >>>

Analysis at practice level gives insight into overall patterns of service use…

… but much more powerful to take patients known to have received a specific intervention and generate person level controls

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Recruitment and statistical power

Problem of early evaluation

Recruitment starts only after ICP has established itself

Patients need some follow-up time

We have 3 month data lag

Performing analysis after end of first year – only 1495 eligible patients

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Summary measures on matching

Matches drawn from population of similar PCTs

Controls well matched in all categories

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Output indicators for cases and controls

+0.09 (p=0.519) -18 (p=0.758)

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Final thoughts

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Understanding year one of the iNWL ICP

• ICP is an ambitious programme of transformational change, being implemented at a time of major reform in the NHS

• Substantial progress was made in designing and implementing a highly complex intervention, and had brought together diverse health and social care providers

• However, it was in the early stages of change and it was too early to demonstrate benefits in terms of service use and patient outcomes

• After year one a second pilot in outer North West London has been established. Move towards a more ambitious ‘whole systems’ approach based on risk stratification rather than disease pathways, in both pilots

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Lessons for evaluation

• International evidence suggests a minimum of three to five years before there is an impact on activity, patient experience and outcomes

• Important to time evaluation accordingly and manage expectations on when changes might become apparent (and detectable)

• However there is value in continuous monitoring of outcomes, particularly when contrasting change within the local context with what is happening elsewhere

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Further information

www.nuffieldtrust.org.uk

http://www.nuffieldtrust.org.uk/publications/evaluation-

first-year-inner-north-west-london-integrated-care-pilot

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