Hannah Farrar, Director of Commissioning at NHS London, looks at defining and promoting integrated care across the capital.

1. Integrated care
London’s programme of change

2. ELIC Referral Management
The integrated care landscape in London is complex GP and Acute Consultant-led
approach to improving the
Brent Gynaecology pathway quality of GP referrals to OPD
GP and Consultant jointly-led Waltham Forest Community
service in the community UCLP Dermatology service Redbridge ICM
Tariff research; whole pathway Royal Free Building on the B&D ICM
Brent (LA led initiative) metrics; integrated cancer Post-acute care provided in a Whittington Health
system, creating ‘patient pull’ community setting Care of elderly; enhanced
recovery; co-morbidities in Tower Hamlets Primary Care
NWL Ealing ICO Investment Programme
LTCs (e.g. Diabetes, heart
Camden ICO Camden Enfield failure; chromic pain) (235,000)
NWL integrated care pilot Frail, older Community Care packages e.g.
Diabetes and older people people with MSK service Diabetes, COPD, CVD, 0-
Waltham Forest ICM
Harrow
multiple Barnet 5’s, MH, Community Virtual
Building on the B&D
H&F continuity of care pilot conditions Ward
ICM
bringing together social care Primary Care Discharge
and GP services for people Waltham Facilitation Service at Queen’s
with high likelihood of hospital Haringey Forest A&E
admissions GP and nurse-led service at
Hillingdon Brent
Redbridge
A&E to redirect patients to the
Westminster Diabetes most appropriate services in
Service Camden
the community
Islington City &
Multi-disciplinary specialist Ealing
Hackney
diabetes teams including Havering
primary and secondary care Westminster Risk based support for
Tower Barking and
working in two bespoke sites City Newham Havering
patients over 65 through
H&F K&C Hamlets Dagenham
community Matrons who
K&C District Nursing Case Hounslow manage care
Management
Practice-based MDT approach Southwark Barking and Dagenham ICM
to avoiding unnecessary Targeted case management for
hospital attendances Richmond Wandsworth Lambeth people at high risk of hospital
Greenwich admissions
Wandsworth Community Lewisham Bexley
Virtual Ward Newham Community Virtual Ward
GP-led model for coordinating Risk based support for patients most
Merton likely to need hospital treatment
community services and
preventing admissions to Kingston
hospital Sutton & Merton Hip & Knee Bexley Care Navigation Team
service Nursing/OT-led team within A&E
Wandsworth Diabetes Sutton at QMS and QEH to redirect
Service Bromley Admission patients to the most appropriate
Your Healthcare Lambeth Living Well Avoidance Service
Vertical integration of services service
Kingston Collective Croydon Builds on successBromley
of
including secondary care with Integrated health and NESTA funded pilot – the PACE pilot QMS Bexley : Design a health
shared guidelines and social care services for co-design of mental campus focus on elderly
referrals services older people health pathways care, integrated primary and
Croydon Virtual Ward secondary services
The map is under development Lambeth & Southwark Co-ordinated services to King’s
Community Diabetes Service patients at the highest risk of Health Greenwich Virtual Admissions
in partnership with clusters and Virtual clinics and hospital admissions using Partners ICO Avoidance Team
local authorities multidisciplinary intermediate processes and practices of Frail older Prevention of emergency
team acute wards people admissions 1

3. Since 2010, NHS London has focused its support on developing three
integrated care systems…
Imperial AHSC UCL Partners KHP AHSC
 The original Darzi NWL Integrated Care Pilot Whittington Health Lambeth and Southwark
Integrated Care
pilot in London had • ~550k catchment ▪ 440k catchment ▪ 517k catchment
limited vision and population population
Catchment population
engagement
population ▪ Initial focus: diabetes ▪ Initial focus on older
and frail elderly, c15k people, c49k over-65s
diabetics and 26k over
75s
▪ Coordination of care ▪ Transfer of community ▪ King’s College Hospital,
 NHS London and across providers (acute, services from Haringey Guy’s & St Thomas’
the three AHSCs Operating community, primary, and Islington into and SLaM NHS FTs
decided to pilot model social care) with shared Whittington Hospital working with NHS
Integrated Care in clinical practices and Lambeth, NHS
three geographies information Southwark and LBs
▪ In delivery stage ▪ Mobilisation and ▪ Full go-live of new
▪ Pilot ends June delivery phase pathway April 2012
Time-
 The aspiration was scales 30, 2012 ▪ Roll out through priority
LTCs and broader
to focus on
population 2012/13
population health
and work with all
▪ Avoid 1,753 admissions ▪ Improve outcomes for ▪ Better quality of care
partners (ie.
across pilot patients at the minimum and patient experience
primary, secondary, Expected ▪ Avoid 3,700 necessary cost; with a reduction in
social care, outcomes attendances across ▪ Reduce unnecessary system costs
community and
mental health). pilot hospital admissions and
▪ Saving of £12.3m from reduce utilisation of
emergency admissions acute care
and £0.2m from A&E
2

4. … on this basis, we can now define the key characteristics of an
integrated care system
Definition
Integrated care systems address specific patient needs using case management. They enable improvements
in the care provided to individuals with long term conditions or high users of services. Integrated care systems
need to be supported by multidisciplinary groups working across health and social care. They focus on
population health and use risk stratification to provide evidence-based care on a proactive and planned basis.
Integrated care systems should deliver:
 Better patient experience
 Better clinical outcomes
 Lower cost, better productivity
Five enablers needed to make integrated care
Seven core components of an integrated care
systems a success
systems
 A patient registry  Clear accountability and joint decision-making
 Risk stratification  Patient, user and carer engagement and
 Common clinical protocols and defined but involvement
tailored care packages  Clinical leadership and cultural development
 Individual care plans  Aligned incentives
 Proactive and planned care delivery  Information sharing
 Case conferences by multidisciplinary teams for
only the most complex patients
 Clinical audit and performance management by
multidisciplinary teams of their performance and
that of their peers
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5. …which has the potential to deliver the aspects of co-ordinated care that
are most important to patients and communities
24/7
Out of Named care Support for Participative Access to
hours care coordinator self care tailored
management planning information
and care
record
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6. Across London, integrated care systems could support the
achievement of commissioner QIPP savings
£
At least Up to
1m £474m
Londoners could potential commissioner
benefit from case savings across London
management1
1 Total population with Long Term Conditions (LTC) from GP QOF registries, with age profile based upon national prevalence rates by age quintile (Decision Resources). Elderly
(75+) estimated from PCT primary care populations by age quintile (Department of Health). The proportion of individuals with co-morbidities estimated from hospital admissions for
patients aged 19-74 with one or more LTC diagnosis on any admission in that year (HES 2009/10 for all London). This figure excludes the children’s segment.
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7. Implementing integrated care systems across London could save
commissioners up to £474m
Commissioner (all London PCTs) Acute Providers
(18 acute NHS Trusts plus FTs )
Level of ▪ £0.9bn reduction in spend required to ▪ £1.4bn to £1.6bn cost saving required to
financial remain within budget achieve financial viability (1% net
challenge to surplus) for 18 acute NHS Trusts
2014 / 2015
▪ Gross saving in acute £663m ▪ Reduction in acute -£643m
spend1 income1
-£160m +£40m
Financial ▪ Investment in new ▪ Income from new
impact of community proactive care community proactive care
Integrate Care -£29m +£489m
▪ Integrated care ▪ Change in costs (includes
programme costs +£474m £52m from LOS -£115m
improvement2)
SOURCE: SaFE 2011, Sector 5-year strategic commissioning plans 2011
1 £20m difference in the reduction in acute spend by commissioners and the reduction in acute income for providers corresponds to a reduction in payments by the commissioner to NHS
London for emergency activity above threshold
2 Total potential saving from LOS reduction through integrated care is estimated at £52m; however, the potential reduction by 2014/15 shown in subsequent analysis is limited to £29m due to
20% cap on cost savings
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8. Integrated care systems are emerging across London…
Enfield
Harrow Barnet
Waltham
Haringey
Forest
Hillingdon Brent
Redbridge
Camden Islington City &
Ealing
Hackney
Westminster
Tower Newham Barking and
H&F K&C City Hamlets Dagenham Havering
Hounslow
Southwark
Richmond Greenwich
Wandsworth Lambeth
Lewisham Bexley
Merton
Kingston
Bromley
Sutton
Croydon
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9. But learning suggests setting up an integrated care system takes time
and requires careful planning
Setting up a pilot requires up to 12 months of planning alongside considerable clinical and managerial
engagement. Five steps have been identified as key to setting up an integrated care community.
Operational
launch
Sign-up by
A detailed all parties
operational
A plan
business
case
A coalition
of
leadership
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10. NHS London has developed a programme of support and joint
learning for the integrated care system coalitions of leadership…
Electronic community A series of problem Monthly
of practice solving workshops teleconferences
• Relevant policy documents • Finance modelling – health • National and regional
• Discussion forum and social care policy updates
• Information on forthcoming • Integrated IT • Cluster updates
events • KPIs for integrated care • Joint problem solving
• A toolkit on setting up • Patient experience and opportunities, on key
integrated care systems involvement topics
• Aligning incentives
www.networks.nhs.uk/nhs- • Integrated commissioning
networks/london-integrated-
care-peer-learning-forum
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11. … and is supporting establishment of whole-population integrated care
systems
Key questions being addressed
 Most appropriate operating/governance model
 Financial model that best delivers both quality and efficiency across the whole system
 Integration of health and social care
 Commissioning models for integrated care
Inner North West London approach North Central London approach
 Procuring external consultancy support  Development of a long-term programme
to extend the current pilot and design a to develop a whole population integrated
framework for whole population care system and address system-wide
integrated care enablers:
 Informatics solution
 Links to Inner NWL Community Budget  Year of Care funding/tariff model
pilot that is reviewing public sector  Commissioning/contracting model
spend and developing a business case  Workforce requirements
for whole population re-design.
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