Gerald Wistow and Judith Smith report on their evaluation of the North West London Whole Systems Integrated Care (WSIC) programme.
There is broad agreement in policy circles that integration of health services and social care is something that really should be sorted out, and soon. Evidence from the Nuffield Trust and LSE evaluation of the largest of the original 14 National Integrated Care Pioneer sites announced by the then Health Minister Norman Lamb in 2013 suggests that this is in fact much more difficult than it might at first appear.
Our research – from February 2014 to April 2015 – sought to provide an independent assessment of the way in which the WSIC programme was designed and implemented in its early stages, and how far it was on track towards achieving its objectives. It was commissioned by Imperial College Health Partners (ICHP), and funded by ICHP and the collaboration of clinical commissioning groups (CCGs) in North West London.
WSIC’s territory stretches out from Westminster to the outer suburbs and comprises two million people with significant variations in their levels of deprivation and health status. The programme brings together a complex web of agencies including eight clinical commissioning groups (CCGs), seven local authorities, nine hospital trusts, four providers of mental health and/or community services and over 400 GP practices.
We found that the North West London approach to developing integrated care was large in scale, ambitious and very well resourced, when compared with other integrated care pioneers. This was reflected in the scope and scale of its management and development resources, its extensive programme for co-designing new models of care, and the impressive commitment it showed to involving local people and organisations in its planning and governance.
The project has however been costly, with funding for direct costs of planning and design to the tune of £24.9 million over three years to 2015/16, including a £7.9 million bill for management consultancy in the first two years. We know from the body of prior research on making large-scale change in health care that it is complicated and time-consuming to win the hearts and minds of health and social care professionals, change long-embedded working practices and get new systems in place in a sustainable manner.
On this basis, £25 million potentially represents a sound investment - that is, if it is successful in creating an effective model of ‘whole systems’ change that makes a real difference to the care that frail and vulnerable people receive.
The WSIC programme has made some impressive progress. It seeks to deliver better coordinated care and promote independent living at home, largely for frail older people, initially.
To do this, WSIC made significant investments in a very inclusive process of co-design and planning, before going on to develop nine pilot schemes of integrated care known as ‘early adopters’. The initial co-design phase was completed in spring 2014 more or less on time, but progress with the WSIC programme slowed significantly as implementation began, in a pattern that is all too familiar to observers of attempts at large-scale transformation in health services.
Difficulties in establishing data sharing and information governance, capitated payment systems, provider partnerships and differences in professional culture all hampered progress towards implementing new approaches to care planning, coordination and service delivery. Removing these barriers is not wholly in the gift of local WSIC leaders – some require the national action promised to the pioneers at the outset. Nonetheless, action to resolve knotty issues such as shared patient records had not been forthcoming during our research.
While the programme wisely avoided setting early output targets, the systematic monitoring of service use, patient and user-experience and overall cost-effectiveness is now required. Our research revealed concerns that departures of key senior managers earlier this year weakened WSIC’s leadership. This at a time when implementation of the early adopter schemes required attention to tough transactional issues including contracts, data-sharing, funding flows and service change.
It is always hard to be a front-runner; there are risks to be taken, without assurance of immediate success. However, pioneers also have to demonstrate dogged determination and a willingness to keep learning from both successes and mistakes. WSIC has to date shown a very real readiness to do this, including through the commissioning of formative evaluation which has offered regular feedback of findings and insights.
Integrated care in NW London is now at a crucial tipping point between an extensive programme of planning and the tough business of actually making change to how services are experienced by vulnerable people and their families. The pioneer now needs to make a real difference to their lives, and soon.
For more information on the WSIC programme, go to: integration.healthiernorthwestlondon.nhs.uk/
For more on the work of PSSRU, go to: www.pssru.ac.uk/index-kent-lse.php
Smith J and Wistow G (2015) ‘Learning from an intrepid pioneer: integrated care in North West London’. Nuffield Trust comment, 1 October 2015. https://www.nuffieldtrust.org.uk/news-item/learning-from-an-intrepid-pioneer-integrated-care-in-north-west-london