1. Launching an integrated
care organisation for North
West London
Integrated Care in London GP – Specialist collaboration
London:
and ‘Teams Without Walls’
Wednesday 9th February 2011
Dr Mark Spencer & Dr Rebecca Rawesh

2. There are five things we want to this afternoon
1 Overview of IC pilot and what we’re trying to
achieve
2 Structure, governance and organisation
design for the IC pilot
3 Fi
Financial arrangements and implications of
i l t d i li ti f
the IC pilot
4 Clinical engagement strategy
g g gy
Integrating clinical relationships and creating
5
multi-disciplinary systems
1

3. OVERVIEW OF IC PILOT
The NWL integrated care pilot brings providers together to work across
organisational boundaries to improve care cost-effectively
Why integrated care?
Brent: 37,000
▪ Current outcomes in
C t t i Ealing: 25,000 patients
care for the elderly and patients
people with diabetes in
NWL leave room for Westminster:
improvement 122,000
,
patients
▪ Locally there is much
enthusiasm for
integrated working and
improving collaboration Hounslow: Hammersmith and Kensington and
across clinicians 33,000 patients Fulham: 101,000 Chelsea: 62,000
patients patients
1) Become a ‘beacon’ for delivering integrated care to the local population
beacon
What are involving primary, secondary, community, social and mental health sectors
we trying
2) Decrease emergency admissions by 30% and nursing home admissions by
to
achieve 10% for diabetics and frail elderly
in NWL? 3) To overall reduce cost of these groups by 24% over 5 years
4) Significantly improve patient experience
2

4. 3 The NWL integrated care pilot will remove barriers to enable the system
to implement whole system change across care pathways
Overview Clinical changes Clinical enablers
▪ The 8 PCTs and
providers in NWL face Aligned incentives Joint governance
a £1bn funding gap
by 2015
▪ GPs from across 5
PCTs, Imperial College
Healthcare, social
services and central
London Community Outcomes incentives will be aligned Representatives from each provider
health have worked across providers, and providers will organisation will be part of a joint
together to design a pilot Diabetes & the Elderly share a pool of funding governing, decision-making body that
MDTs manage the health monitors and acts on issues
▪ This has been of a population, and
supported by Kaiser specific programmes Information sharing
I f ti h i
Organisational development
Permanente, Nuffield target patients based on and culture
Trust, King’s Fund and need and risk
McKinsey stratification
and Co.
▪ The pilot will have major
j
clinical and financial Other
Oth opportunities
t iti
benefits A group creates overall
coordination across
providers to improve A mechanism for sharing that Leaders and clinical teams spanning
care and meet aggregates patient-level data so that it provider organisations will undertake
commissioning intentions can be analysed and accessed in a joint training and development, and
(e.g.,
(e g reduce LOS) timely, seamless way
y y will begin to develop their own team
g p
cultures
SOURCE: NWL Integrated care working team (Aug 2010) 3

5. Mission statement created by TIMB
1) Deliver high quality care for patients that makes an improvement in patient
outcomes and satisfaction
2) Increase the level of trust, coordination and collaboration across clinicians with
GPs, consultants and other providers working together towards better patient care
3) Become a ‘beacon’ for delivering integrated care to the local population
4) Create a vehicle for delivering productivity and efficiency improvements within
and across the various providers
5) Improve the satisfaction of clinicians and healthcare workers across the sector
through their ability to deliver proactive care
6) Make the IMB, as a representative group of providers, accountable for ensuring the
successful and timely launch of the IC pilot
7) Ensure all providers are on-board and signed-up to pilot by g
) p g p p y giving ample
g p
opportunity to engage in the project and shape the IC
8) Ensure that all stakeholders are engaged including third sector, users of services
and carers of those users
SOURCE: Interviews, Transitional IMB 4

6. STRUCTURE AND GOVERNANCE OF IC PILOT
Governance model
IC pilot LA Patients &
PCTs ACV1
commis Public
▪ The IC pilot will establish
new relationships between
providers in NWL Mental
▪ These will be based on CLCH Imperial LA providers Third Sector
Health
contractual relationships
rather than a new
organisation
▪ The IC pilot will establish
p GP practice
mechanism for co-
ordination and funding flows GP practice GP IC
amongst providers leadership
▪ The Management Board
(IMB) will agree resource GP practice
IC
plans, funds sharing, Pilot
membership, etc GP practice
▪ Decision making will be by IMB
consensus
Providers
LEGEND
▪ The IC pilot will include GPs, Imperial, CLCH, Local Authorities and Joint vehicles
Mental Health trusts Commissioners
▪ GP practices elect leaders to represent primary care in the IC pilot. Providers
▪ Providers will pool a small amount of funds into the IC pilot to cover Funding flow
F di fl
Pooling of funds
costs of more activity and mgmt
1 Sector Acute Commissioning Vehicle
SOURCE: NWL Integrated care working team (Aug 2010) 5

7. STRUCTURE AND GOVERNANCE OF IC PILOT
Integrated Management Board
IMB Board
(Chair: Prof. Elisabeth Paice)
Imperial (5 votes) GP Practices (11 votes) Central London Local Authorities (1 Third Sector (2 Mental Health (1
Community
C it vote)
t ) votes)
t ) vote)
t )
Healthcare (2 votes)
Claire Holloway /
Claire Perry, Brent: Dr Mandy Craig (James Reilly) Geoff Alltimes, Benn Peter Cubbon,
Managing Director Chief Executive Chief Executive Keaveney, Chief Executive
Officer Officer, London Lead, Age UK Officer
Borough
Tony Graff, Chief Hammersmith &
Ealing: Dr Jennifer Durandt Jane Clegg,
Finance Officer Fulham Roz
Director of
Rosenblatt,
Operations
Diabetes UK
Josip Car, Clinical
Programme Director, Marian Harrington,
Hounslow: Dr Liz Morris
PH Director of Adult
Services,
Westminster City
Julian Redhead, Council
Director of Medicine Hammersmith & Fulham: Dr
Tim Spicer, Dr Simon
Edwards and Dr Peter
Jonathan Valabhji, Fermie
Clinical Lead -
Diabetes
Kensington & Chelsea: Dr
David Taube, Tahir, Dr Simon Ramsden
Medical Director
Edward Dickinson,
, Westminster: Dr Ruth
Clinical Lead - O'Hare, Peter Crutchfield,
Elderly 1 TBC
6

8. Financial modelling suggests that £10m can be saved from emergency
admissions; with a proportion split across the various providers
Funding
F di approach for integrated care pilot year (2011/12)
hf i d il Funding fl
F di flows (2011/12)
£m (based on high-level analysis)2 Amount (£m) £m (based on high-level analysis)2 Incentive Payment
Commissioners in NWL currently spend a 187 Additional Resource
1
disproportionate amount on diabetes and the elderly. £10*m comes out of acute Infrastructure Cost
For a pilot of 380,000 the spend on these groups is care due to IC pilot QIPP Payment
£187
~£187
IC pilot providers agree the care pathways and targets 10*
2 for diabetes and the elderly and propose these to Commissioner
3.30 1.60
commissioners
Commissioners reflect outcomes in provider SLAs and -6.7 2.10
3 Commissioner
other contracts, expecting a decrease of activity they
p g y y
Balance
provide in 2011/12 for the diabetes and elderly pilot1
population
Does the IC pilot IC Joint Venture
Commissioners keep the balance as part of its QIPP 3.3 deliver allocates
4
contribution improvements? funding
The £6.7m that will be contributed by commissioners
5
via contracts (CQUIN and LES) is divided as follows:
▪ Additional out of hospital resource for more proactive -2.1 No Yes
care (guaranteed payment)
▪ Infrastructure costs to run the pilot (guaranteed -1.6
payment) 3.00 3.00
▪ Incentive payment for outcomes (dependent on 30
-3.0
achieving goals)
Payment for
If outcomes are not delivered by the IC pilot, the £3 acute over-
5 performance
million of incentive funding will not be paid
Any additional savings made by the IC p
y g y pilot will be kept
p Split of incentive payments and additional resource to be
6
by the providers recommended by finance group via detailed modeling
1 Figures are calculated as a best estimate of the commissioning intentions specific to diabetes and elderly based on a pilot population of 380,000
2 Analysis being further developed in current phase of work moving from top-down analysis to bottom-up modelling
* Assumes actiivity removed at full PbR tariff from provider – in reality 30% marginal rate applies for activity reduction in 2011/12 7

9. OVERVIEW OF IC PILOT
Lots of work to be done in the next few months – 7 working groups set up
Workstream
W k t Working group
W ki Responsibilities
R ibiliti
▪ Design the new governance structure for sign-off by IMB including
Governance roles, responsibilities, processes and various enablers required for
Governance collaborating
and Finance ▪ Discuss and problem-solve the various contractual and financial
Finance implications of the IC pilot and how various providers will come
together to deliver the change required
Clinical Working ▪ Define clinical interventions for both Diabetes and Elderly Care (in
Groups
G separate groups) and set protocols and set core clinical agenda
Clinical
▪ Define the ‘solution space’ for local MDT design (e.g., size, duration,
MDT Mechanics frequency of interaction etc.) and develop a general toolkit to support
local implementation
▪ Create and design an evaluation platform with metrics for the
Evaluation patient experience, financial impact, clinical outcomes and change
Evaluation and management to be used during the pilot
and
Research ▪ Identify various research opportunities within integrated care and
Research
discuss possible work and undertake research agreed upon within
the group
▪ Form ‘technical design group’ to decide how to implement the
Information required IT solutions and ‘functional design group’ to decide what the
Information
IT will need to look like
Co-chairs (one GP and one Imperial Consultant) have been
appointed for each working group
8

10. We have already detailed and begun an intensive engagement strategy…
Key dates
y
January February March April Dates
IMB 1 2 3 4 5 ▪ Page 26
Kick-Off
▪ 8th Feb
MDT Support ▪ 1st Mar
Forum (all 1 2 3 4 5 ▪ 23rd Mar
Clinicians) ▪ 13th Apr
▪ 27th Apr
GP Road-shows 1111 1 1 12
▪ Various
GP Practice-by-
2
▪ Various
Practice Visits
One-on-one
Interviews 1 1 11 1112 ▪ Various
Imperial Fortnightly Imperial internal IC pilot meetings (when invited)
Engagement <Best approach to be defined with Imperial >
▪ TBC
Other Provider
Engagement
<Various mechanisms depending on provider> ▪ TBC
9

11. 3 We have agreed the care pathways for frail elderly and diabetic patients
The clinical working group for the elderly identified priority areas The clinical working group for diabetes agreed roles and quality
to improve care in the pilot elderly population through integration standards, and so the pilot will remove barriers to this
Segments # of patients in pilot1 Segments # of patients in pilot1
In care 2,462 High needs 1,976
Support needed 3,337
3 337 Intermediate needs 3,969
3 969
Independent but at risk 2,850 Low needs 9,454
Independent and well 10,599 Newly diagnosed 1,106
Early identification of elderly Impact evidence Programme elements Impact evidence
1
frail people/risk stratification ▪ 30% reduction in bed Short term
days Risk Case ▪ Higher % with BP
stratification management under 140/80 and
2
Prevention programmes ▪ 20-80% reduction in
(falls, medicine management) emergency admissions cholesterol under 4.5
Telemonitoring ▪ Improved HbA1c
over time Diabetic
& telephone
Pro-active care planning and ▪ Reduction in registry
support control (<7.5)
3
delivery by community team readmissions ▪ 100% uncontrolled and
%
▪ 40-70% reduction in Improved
Patient complex patients on
education care plans
Appropriate falls screening
programmes
4 Longer term
emergency responses ▪ Improved satisfaction ▪ 20-25% reductions in
▪ People getting the Multi-disciplinary Patient-held admissions
Pro-active case management “right care” across team meetings records ▪ 40% Reduction in bed
5
of complex patients social and health days
Clinical ▪ 80% Reduction in
Care planning
6 Improved information flows education amputations
Both pathways are based on individually case managing patients through
p y y g gp g
pathway-based MDTs and applying a risk-stratified set of interventions based on individual needs
1 Pilot population estimated to be 380,000
SOURCE: NWL Integrated care working team (Aug 2010) 10

12. MULTI-DISCIPLINARY SYSTEMS
Our vision for a multi-disciplinary system – 7 core elements of the NWL
model
Element Description
1  List of covered population and associated data
Patient from all setting of care
registry
2  Segmentation of individual patients by risk
Risk
stratification
3 Clinical  Development of clinical protocols and care
protocols and packages (including activity and resource
care packages requirements) for each risk group
4  Creation of individual care plans in one-to-one
Care plans meetings between clinicians and patients
5  Delivery of care plans by multiple professional
Care delivery groups
6  Discussion of management of most complex cases
Case
conference
7  Review by MDS of patient experience, clinical
y p p ,
Performance
P f 
 outcomes, financial performance and team
review effectiveness

SOURCE: Team analysis 11

13. OVERVIEW OF IC PILOT
Following this phase of work; mechanisms will be in place to monitor and
support the IC pilot within the first year
Post-Pilot
Pilot
Pre-Pilot
▪ Start of Dec 2010 to end of ▪ End of April 2011 to end of ▪ End of April 2012 onwards
Timeline April 2011 April 2012
▪ Develop work-streams and ▪ Provide on-going support to ▪ Agree ongoing resourcing
Focus of work enablers to IC pilot through MDTs across sector that and funding based on
various working groups have been formed decision to continue pilot or
▪ Ensure milestones are ▪ Continue roll-out of more not
reached, through practices and MDTs across ▪ Monitor progress through
transitional IMB, and the sector (and/or sign-up evaluation platform and
decisions made on-time for more) performance management
launch ▪ Monitor progress through processes
▪ Support and coordinate evaluation platform and ▪ TBD (based on success of
ramp-up across NWL to performance management pilot): Introduce new
form MDTs processes pathways and expand
scope or partners of pilot
Enabler to ▪ Clinical Engagement ▪ Clinical Engagement ▪ Clinical Engagement
success ▪ Rapid input and work from ▪ Identification of early ▪ Output from research group
working groups success metrics on new opportunities
12

14. Questions for discussion
1 How can we learn from you?
2 How should ‘organisational development be
organisational development’
handled during the IC pilot?
What financial arrangements need to work
3
for
f success? ?
4 How can we get clinicians to work together
more collaboratively?
y
13