The North West London Integration Toolkit is intended to support communities, people and partners as they work towards the shared vision of integrated care. The toolkit is the culmination of over 200 individuals and organisations across North West London coming together to share knowledge and develop ideas as to how to implement whole systems integrated care. For more information as to how the toolkit was developed please read about our journey. The toolkit is a living document and repository of our collective learnings. It will evolve and be updated as local areas start to implement their plans and lessons are learned and shared, such as through the ‘Toolbox’ above. Comments and contributions are welcomed.
People in North West London have come together to create a vision for ‘better-co-ordinated care and support, empowering people to maintain independence and lead full lives as active participants in their community.’
31 health- and social-care organisations across North West London have made a commitment to this vision, and we are one of 14 national pioneers for joined-up care. Together with lay partners, we have considered some of the difficult questions that this vision raises through the Whole Systems Integrated Care programme. From September 2013 to January 2014 working groups have met to discuss populations and outcomes, General Practitioner (GP) networks, provider networks, commissioning and finance, and informatics.
This toolkit distils the work of these groups into a web resource that we hope will be useful to commissioners, providers, voluntary organisations and communities, to help. They design new and innovative models of care within North West London and elsewhere.The toolkit is a living web-based resource and will be updated frequently as local areas implement their plans for integrated care and lessons are learned and shared.
This chapter lays out in detail our vision for delivering care that is centred around the needs of people, the reasons of why the way care delivery today needs to change to meet that vision, the current efforts we are building upon and the aspiration of where we want to get to.
- What is the vision? - View Section
- What is the case for change? - View Section
- How will it feel? - View Section
- What have we achieved already? View Section
This chapter is important because it explains what we mean by Embedding Partnerships and why this is crucial to the success of making joined-up, person-centred care a reality for the people of North West London. This chapter speaks from the voice of the lay partners, who have played a central part in the co-design of all elements of this toolkit.
- Introduction - View Section
- What was our approach to the co-design phase? - View Section
- Why is Embedding Partnerships important? - View Section
- How can we support lay partners? - View Section
- How can we co-produce effectively with lay partners? - View Section
- What is the impact of coproducing with lay partners? - View Section
This chapter explains why we should group the population and lays out the whole system proposals to grouping the population across North West London. This grouping has been co-designed by professionals across health- and social-care, as well as lay partners.
- Why should we group? - View Section
- What are the different ways we can group? - View Section
- What approach should we take? - View Section
- How are individuals assigned to the groups? - View Section
- How do we understand individual needs within groups? - View Section
- How do local areas decide which groups to focus on? - View Section
- How will we ensure standards and accountability? - View Section
This chapter explains how commissioners, the buyers of health, and providers of care can think about outcomes. In order to do this, they will need to understand how outcomes can be measured, how they can measure individual and personal goals and then how they can be tracked over time.
- How do we think about outcomes holistically? - View Section
- How can we convene for co-designing outcomes? - View Section
- How do we define outcomes and metrics? - View Section
- How do we ensure personalisation? - View Section
- How will outcomes be tracked and measured? - View Section
This chapter explains how providers of care can design a new and innovative model of care. In order to do this, providers will need to understand the essential features of a model of integrated care, and will need to understand the costs of their proposed models.
- The case for change and innovation - View Section
- Convene for co-design - View Section
- Understand current care and future needs - View Section
- Setting vision and goals that will achieve the desired outcomes - View Section
- Design the new model of care - View Section
- Deciding who will do what, where and when - View Section
- Costing the whole model - View Section
- Assessing the impact of the model - View Section
- What do we want to achieve by pooling budgets? - View Section
- What budgets could we pool? - View Section
- What are the joint governance options? - View Section
This chapter explains why and how capitation, a form of funding, could fund Whole Systems Integrated Care. Capitation incentivises personalised, innovative care that keeps people well at home. Commissioners need to work through important design issues to best incentivise local outcomes and mitigate risks. This chapter focuses on how commissioners can calculate the capitated budget given to a provider network.
- Chapter 8 - Introduction - View Section
- What is capitation and what are its alternatives? - View Section
- Why is capitation often used in integrated care systems? - View Section
- What are the key design choices for capitation? - View Section
This chapter is important because it will help GPs understand how they can form or develop networks. It lays out the case for change for GP networks in North West London, it will present the organisational models that GPs could use to form networks and it will summarise the tools available through the programme for network development.
- Chapter 9 - Introduction - View Section
- What is the case for change for GP networks? - View Section
- What are the organisational options for GP networks? - View Section
- What resources are available to help develop GP networks? - View Section
This chapter explains the options for how providers can structure their networks. It also sets out the approach about how they can agree changes in funding needed to support new models of care, manage performance across the network and share risks.
- Chapter 10 - Introduction - View Section
- What are the benefits of provider networks? - View Section
- What are provider network governance options? - View Section
- How can provider networks agree to change how resources are distributed? - View Section
- How could performance be managed? - View Section
- How could risks and savings be shared? - View Section
This chapter is important because it explains what new informatics requirements Whole Systems Integrated Care will generate and how commissioners can start implementing them. The new approach to care will need to be supported by robust information and the informatics infrastructure needs to be able to deliver integrated care.
- How did we identify the informatics functional requirements? - View Section
- What do service users need? - View Section
- What do providers need? - View Section
- What do commissioners need? - View Section
- What is the plan to address these needs? - View Section
Whole Systems Integrated Care (WSIC)
In Whole Systems Integrated Care, health- and social-care services work together to create innovative ways to deliver person-centred care. It aims to deliver high-quality care, to empower and support people to maintain independence and to lead full lives as active participants in their community.
National pioneer process
North West London is one of fourteen areas chosen as "pioneers” in a national programme developed to encourage ambitious and innovative approaches to deliver integrated care in a person-centred way. The lessons from all the pioneer programmes will be drawn on by other areas as they build their own systems over the coming years.
Co-design is a process that brings together clinicians, commissioners, the voluntary section, service users and other service providers to develop an improved way of working. Using a co-design process helps build care delivery that fully takes the service user perspective into account from the get-go, helping to create a service that really meets people’s needs. For a detailed how-to guide on co-design, see Chapter 3: How do we ensure service users and carers are involved throughout?
Embedding Partnerships is the cross-cutting module of the Whole Systems programme that focuses on co-producing integrated care with patients, people who use services and carers. It is the means by which we worked together as a team of professionals and lay partners to co-design our whole systems solutions and tools.
A lay partner is a patient, a person who uses services or a carer who is involved in the North West London Whole Systems Integrated Care programme via Embedding Partnerships. Lay partners act as the guardians of the vision for person-centred, joined-up health- and social-care and act to ensure that all aspects of the programme benefit from the input of patients, people who use services and carers from the very start. The term "lay partner” was chosen by the individuals themselves.
Models of care
A model of care is the whole set of interventions and innovations that combine to empower and support individuals and their carers. Partners across North West London will need to come together to innovate new models of care.
Multi-disciplinary teams (MDTs)
MDTsshould bring together all of the relevant care professionals, volunteers, and other partners who provide care for given individuals, including the individuals and their carer(s). The professionals included should be able to effectively look after the physical, mental and social-care and support needs of the individuals covered. The vital part of an MDT is to facilitate conversations, care planning, team working and referrals amongst care professionals and their partners.
A personal budget is an amount of money allocated directly to individuals for their own care, or managed by a local authority on behalf of an individual. They are currently mostly used in social-care for FACS-eligible individuals. A personal budget can either be managed by a care coordinator on the individuals’ behalf, or used by individuals on whatever they think will most improve their quality of life.
Capitation is a payment model where commissioners pay for all the care a particular population group needs in one defined amount, and reward the providers for meeting overall health targets, rather than for doing particular services well. This should encourage care providers to innovate flexibly on models of care to deliver care in the way that keeps people as well as possible.
In a provider network is where multiple providers from across health- and social-care work together with shared incentives to deliver joined-up care. A provider network can create multi-disciplinary teams which sit together, look after a shared list of people with shared goals and share clear line management.
In a GP network, multiple GP practices join together to offer services and realise economies of scale that would not be possible for single practices. GP networks can join up with other providers to make a provider network.