The Nuffield Trust's Holly Holder presents on a project in partnership with the London School of Economics to evaluate a whole systems approach to integrated care in North West London.

1. 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

2. Presentation structure
1. Methodological challenges
2. What is the Whole Systems Integrated Care
programme?
3. Our methods
4. My reflections

3. 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?

4. 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

5. 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

6. North West London
• 2 million population
• 8 local boroughs
• 8 clinical commissioning groups
• £4+ billion annual health and
social care spend

7. 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

8. Which organisations are involved in WSIC?
Source: WSIC Integrated Care Toolkit

9. 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

10. Two levels of operation: pan-NWL level
Adapted from WSIC Integrated Care Toolkit
Governance structures

11. Activities at a pan-NWL level
Tackling the ‘tough nuts’ once at the pan-NW London level...
Source: WSIC Integrated Care Toolkit

12. 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

13. The process happening at the local level
WSIC’s ten-step methodology for developing whole systems integrated care
Source: WSIC Integrated Care Toolkit

14. 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.

15. 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)

16. 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

17. 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?

18. 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

19. 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.

20. 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

21. 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

22. www.nuffieldtrust.org.uk
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