Daniel Elkeles, Director of Strategy, NHS North West London, discusses how to write a business case for integrated care in the current financial climate.

1. Integrated care in
North West London
Making the business case ‘stack up’
Daniel Elkeles
Director of Strategy NHS NW London
10 January 2012
Serving the North West London Cluster

2. Producing our business case required us to address 5 areas
1
Joint governance
Integrated Management Board with a shared
performance and evaluation framework
2
Aligned incentives
through an innovative financial model
3
Information sharing
to access and analyse data in a timely fashion
4
Patient, user and carer
engagement and involvement
5
Organisation and culture development
Serving the North West London Cluster

3. The NWL Integrated Care Pilot
Improve the quality of patient
care for patients with diabetes and the elderly
Local Multi-Disciplinary Groups… …working in a Multi-Disciplinary System
Group
1 5
Sub-Group Patient Care
registry delivery
Practice
Social care
2 6
Specialist
Risk Case
stratification conference
GP District Community
nurse matron Mental 3 7
Health Clinical 
Performance
Specialist protocols & 
review 
care packages
Practice Social Community 4
nurse care Mental
Acute Care plans
worker Health
Specialist
1) Improve patient outcomes and experience through collaboration and coordination care
What are we across providers (4 hospitals, 3 community providers, 93 GP practices, 5 social care
trying to organisations) with shared clinical practices and information
achieve in 2) Over 5 years decrease hospital usage including emergency admissions by 30% and
NWL?
nursing home admissions by 10% for diabetics and frail elderly through better more
proactive care
3) Reduce the cost of care for these groups by 24% over 5 years
Serving the North West London Cluster
SOURCE: NWL ICP Operations Team

4. A large number of providers taking part in this pilot
Ealing CCG
Great West CCG (Hounslow)
West London CCG (K&C)
Westminster CCG
Hammersmith and Fulham CCG
Serving the North West London Cluster
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5. Over the last 6 months, the ICP providers have organised themselves into
10 multi-disciplinary groups (MDGs) that reach over 550K patients
K&C North CLH
H&F Small Practices
Acton ▪ Practices: 11 ▪ Practices: 17 ▪ Practices: 13
▪ Practices: 12 ▪ Diabetes: 1221 ▪ Diabetes: 2,109 ▪ Diabetes: 2,723
▪ Diabetes: 1,551 ▪ Elderly: 1325 ▪ Elderly: 3,407 ▪ Elderly: 3,420
▪ Elderly: 2,845 ▪ Total patients: 37,951 ▪ Total patients: 74,370 ▪ Total patients: 63,636
▪ Total patients: 54,917
Chiswick
▪ Practices: 9
X Victoria
▪ Practices: 8
▪ Diabetes: 1,015 ▪ Diabetes: 1,225
▪ Elderly: 2,218 ▪ Elderly: 2,618
▪ Total patients: 41,630 ▪ Total patients: 47,674
H&F North Central
▪ Practices: 9
▪ Diabetes: 2,134
▪ Elderly: 2,528
▪ Total patients: 72,486
H&F Central H&F South Fulham K&C South
▪ Practices: 5 ▪ Practices: 6 ▪ Practices: 14
▪ Diabetes: 1,113 ▪ Diabetes: 688 ▪ Diabetes: 1,667
▪ Elderly: 1,790 ▪ Elderly: 1,700 ▪ Elderly: 3,635
▪ Total patients: 39,908 ▪ Total patients: 38,302 ▪ Total patients: 73,492
SOURCE: NWL ICP Operations Team Serving the North West London Cluster

6. A simple way of describing the ambition
GP Practice Pilot Catchment
Unit of
measurement
across pilot
Reduction in
▪ Avoid 7 ▪ Avoid 28 ▪ Avoid 1,753 ▪ Avoid 2,080
admissions per admissions per admissions admissions across
emergency
~2,000 patients ~8,000 patients across pilot of catchment of
admissions
506,000 600,000
population population
▪ Avoid 15 ▪ Avoid 59 ▪ Avoid 3,700 ▪ Avoid 4,390
Reduction in
attendances per attendances per attendances attendance across
A&E
~2,000 patients ~8,000 patients across pilot of catchment of
attendances
506,000 600,000
population population
Total ▪ Saving of £50,000 ▪ Saving of ▪ Saving of ▪ Saving of £14.6m
reduction in from emergency £200,000 from £12.3m from from emergency
emergency admissions and emergency emergency admissions and
care £1,250 from A&E admissions and admissions and £0.4m from A&E
£5,000 from A&E £0.2m from A&E
Serving the North West London Cluster
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7. How are we doing so far?
Very preliminary data
Emergency admissions
April 2011 - September 2011
SLA base line activity 2011/12 5,561
Actual emergency admissions 5,040
Difference 521
Compared to April 2010 - September 2010
Emergency admissions across NWL -1%
Emergency admissions in ICP cohort -4%
Serving the North West London Cluster

8. Joint governance –
We created a virtual organisation to run the pilot
Serving the North West London Cluster
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9. We set out clearly the responsibilities of each provider in the ICP
Actively participate at case conferences Support and take part in care planning
▪ Identify and prepare patient cases for ▪ Support MDGs in creating initial care plans
discussion (e.g., inpatients, social service for all diabetic patients and 50% of patients
users with health issues, etc.) aged 75 and over (e.g., by providing
seconded nurses to the MDG)
▪ Give specialist input on patient
cases brought by other participants ▪ Modify care plans with patients’ GPs as
needed
▪ Be the expert for the MDG on the full range
of available services and resources
▪ Follow-up on questions and actions
generated through the case conference
▪ Discuss MDG performance, identify
opportunities for improvement, and
allocate out-of-hospital investment
▪ Use the ICP IT tool to see range of patient
data and history across multiple settings
▪ Identify system gaps and
▪ Complete “actions” (referrals) and regularly opportunities
monitor activity
▪ Collaborate with MDG partners on day-to- ▪ Identify best practice across MDGs
day basis (e.g., direct phone call to GP upon
A&E attendance)
Change how care is delivered Review performance & identify improvement
Serving the North West London Cluster

10. Aligning financial incentives –
Funds flow from the Commissioner directly for guaranteed payments
funded recurrently without taking from providers up front
Funding flows (2011/12)
70% marginal rate
for emergency
activity over 08/09
Commissioner Infrastructure / IT baseline held by
SHA
Providers paid for activity MDG
using existing contracts – Resource Readmissions top
PbR for acute and block slide held by PCTs
for MH / Community
Does the IC pilot
deliver Integrated
improvements? Management Board
allocates funding
No Yes
Commissioner x/2 x/2
Balance
QIPP saving
SOURCE: Integrated Care Project Steering Group Serving the North West London Cluster
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11. The costs of running the pilot are £3.4m
Estimated cost, £ ‘000
Commissioner
1,200
Retained
Infrastructure2 1,800 OOH
22%
MDG Performance 8% 51% Care
2,500 reviews planning
Out of Hospital3
18%
Case
conference
Total Funding 5,500
Full year cost for MDGs
in the pilot will need to
1. Commissioners retained £1.2m for other work streams increase to £2.8m
2. Includes non-recurring set-up costs
3. Resource envelope available for Care Planning, Case Conference and Performance Reviews
SOURCE: NWL ICP Operations Team Serving the North West London Cluster

12. Information –
We put in place an IT solution that enables providers to work together
1 2
Patient Risk Stratification Integrated Patient Care Planning
Action: Review
by falls service
Care plan
Action 1
Action 2
Action status:
Action 3 Completed
 Identify high risk patients using population  Plan care for patients, share these plans
segmentation and risk stratification across settings, and monitor progress
 This enables proactive care to be planned  This helps better coordinate care
3 4
Patient Medical Information Sharing Performance Evaluation
Patient records:
GP
Hospital
Community
 View patient medical information from multiple  Track and evaluate the performance of GP’s
settings surgeries and Multi-Disciplinary Groups
 This enable integrated care to be provided  This helps spread best practice in patient care
Serving the North West London Cluster 11

13. Things we learnt en route…
• Ground conversations by reminding people we are doing this because
we want to improve patient care and make professional’s jobs better
• Be able to explain the concept simply and agree a single performance
metric
• Identify patient cohorts which aligned to NWL PCTs clinical case for
change
• Build a ‘bolt on’ to the existing NHS infrastructure and rules
• Don’t try and redesign the NHS financial payment mechanisms
• Don’t create a new organisation
• Don’t challenge existing or emergent NHS policy
• Take the minimum of funding out of providers up-front
• Invest sufficient resource to set up the pilot and deliver operationally on
the ground the new ways of working
Serving the North West London Cluster

14. What’s next for integrated care in North West London?
▪ Enhance integration with local authorities and
other providers
▪ Continue to develop and enhance the IT tool
▪ Conduct robust evaluation at the end of the pilot
year to understand impact
▪ Scale up within North West London
– Additional +10 practices in INWL already added,
including Chelsea Pensioners
– Roll out across more practices in Inner North West
London and include Hounslow
– Roll out across more Pathways in North west
London (COPD, CHD and Mental Health)
– Replicate in Outer North West London
▪ Expand beyond North West London
– Commercial interest in IT tool
SOURCE: NWL ICP Operations Team Serving the North West London Cluster
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