The North West London Integrated Care Pilot: Innovative Strategies to Improve Care Coordination for Older Adults and People With Diabetes

Abstract

The North West London Integrated Care Pilot (ICP) was launched in June 2011 and brings together more than 100 general practices, 2 acute care trusts, 5 primary care trusts, 2 mental health care trusts, 3 community health trusts, 5 local authorities, and 2 voluntary sector organizations (Age UK and Diabetes UK) to improve the coordination of care for a pilot population of 550 000 people. Specifically, the ICP serves people older than 75 years and those with diabetes. Although still in the early stages of implementation, the ICP has already received national awards for its innovations in design and delivery. This article critically describes the ICP objectives, facilitating processes, and planned impact as well as the organizational and financial challenges that policy makers are facing in the implementation of the pilot program.

Full text

LWW/JACM JAC200183 May 27, 2012 16:0
J Ambulatory Care Manage
Vol. 35, No. 3, pp. 216–225
Copyright C2012 Wolters Kluwer Health |Lippincott Williams & Wilkins
The North West London
Integrated Care Pilot
Innovative Strategies to Improve Care
Coordination for Older Adults and
People With Diabetes
Matthew Harris, DPhil, MBBS, MSc, MFPH;
Felix Greaves, BM, BCh, MPH, MBA, MFPH;
Sue Patterson, PhD, DIC, BSc(Hons), BSoc Sci;
Jessica Jones, PhD, MS; Yannis Pappas, PhD, MA;
Azeem Majeed, MD, FRCP; Josip Car, MD, PhD, DIC, MSc
Abstract: The North West London Integrated Care Pilot (ICP) was launched in June 2011 and
brings together more than 100 general practices, 2 acute care trusts, 5 primary care trusts, 2
mental health care trusts, 3 community health trusts, 5 local authorities, and 2 voluntary sector
organizations (Age UK and Diabetes UK) to improve the coordination of care for a pilot population
of 550 000 people. Specifically, the ICP serves people older than 75 years and those with diabetes.
Although still in the early stages of implementation, the ICP has already received national awards for
its innovations in design and delivery. This article critically describes the ICP objectives, facilitating
processes, and planned impact as well as the organizational and financial challenges that policy
makers are facing in the implementation of the pilot program. Key words: ambulatory care,
community health services, delivery of care, integrated, information systems
THE INTEGRATED CARE PILOT (ICP) is an
innovative program designed to improve
Author Affiliation: Department of Primary Care
and Public Health, Imperial College London,
London, United Kingdom.
The evaluation of the Integrated Care Pilot was
funded by the Imperial College Healthcare Charity. The
Department of Primary Care and Public Health at Im-
perial College London is grateful for support from the
NIHR Collaboration for Leadership in Applied Health
Research & Care (CLAHRC) scheme, the NIHR Biomed-
ical Research Centre scheme, and the Imperial Centre
for Patient Safety and Service Quality.
The authors thank Scott Hamilton for his comments on
an earlier draft of the manuscript.
Dr Car is part-time employed by Imperial College
Healthcare Trust, which is one of the partner organi-
zations in the Integrated Care Pilot.
No ethical approval is required for this article.
Professor Azeem Majeed is guarantor for the article.
All authors contributed to the writing of the article.
the coordination of care for people with dia-
betes and those older than 75 years in North
West London (NWL). Encompassing a popu-
lation of approximately 550 000 people, the
ICP is expected to target an estimated 15 200
patients with diabetes (of whom about 8700
are older than 75 years) and 22 800 patients
who are older adults. The stated aims of this
pilot was to:
1. become a “beacon” for delivering inte-
grated care to the local population in-
volving primary, secondary, community,
social, and mental health care sectors;
Correspondence: Matthew Harris, DPhil, MBBS, MSc,
MFPH, Department of Primary Care and Public Health,
Imperial College London, Reynolds Bldg, St Dunstan’s
Rd, Hammersmith, London W6 8RP, United Kingdom
(m.harris@imperial.ac.uk).
DOI: 10.1097/JAC.0b013e31824d15c7
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216

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The North West London Integrated Care pilot 217
BOX. Key Actions in the North West London Integrated Care Pilot
Early identification of at-risk diabetic or elderly people
Risk stratification using simple assessment scales (combined predictive model)
Proactive care planning and delivery by community team
Care planning shared across care settings including clear guidance for out-of-hours services
Seamless interaction between community and hospital care teams
Appropriate emergency responses
Improved ambulance protocols and assessment integrated with care planning and community
care
Proactive case management of patients with complex conditions
Multidisciplinary teams led by a general practitioner or consultant to ensure that care of patients
with complex conditions reduces risk hospitalization
Improved information flows and system redesign
Improved systems and processes to share patient notes and care plans across care settings
2. significantly improve the patient experi-
ence;
3. decrease emergency admissions by 30%
and nursing home admissions by 10% for
people with diabetes and the frail elderly
through better, more proactive and coor-
dinated care; and
4. reduce the cost of care for these groups
by 24% over the next 5 years.*
The ICP addresses these aims through
patient risk stratification (specifically, risk
of unplanned hospitalization), proactive care
planning and case management, improved
emergency response in the community, and
improved sharing of medical information
between service providers (Box). This is to
be achieved through newly developed and
established financial and governance arrange-
ments, an information technology (IT) tool to
extract and use data from general practices,
acute care trusts community services, social
care, and mental health care services, and
newly developed multidisciplinary groups
(MDGs). Specifically, MDGs meet to discuss
the most complex cases and develop individ-
ually tailored care plans to keep, as far as possi-
ble, patients out of hospital. The ICP has been
the subject to intense media interest†and
*ICP Launch presentation June 2011, Asia House, London.
†BBC Radio 4 “Today” program; BBC 1 Question Time;
Pulse magazine.
received a prestigious Health Services Jour-
nal Award for innovation in the management
of long-term conditions (HSJ, 2011).
In this article, we describe the core inter-
ventions of the ICP, setting the background
for its future evaluation that the authors are in-
volved in. We consider the ways in which inte-
gration is being promoted and at which orga-
nizational and service levels, and we explore
whether and how the organizational change
will impact on patient care.
DESCRIPTION OF THE CARE PRACTICE
The context in North West London
In England, health care is funded from gen-
eral taxation and most care is provided free
of cost to patients. Since 1991, the health sys-
tem has been divided into 2 types of organiza-
tion: commissioners‡and providers of health
care services (Sobanja, 2009). This internal or
quasi-market system is designed to promote
competition and therefore choice and qual-
ity of care for patients. Since 2002, the main
statutory commissioning organizations in Eng-
land have been geographically delineated pri-
mary care trusts (PCTs). These are overseen
‡Commissioning is the planning, contracting for, and
monitoring of health care services, on behalf of their local
population, including buying primary care services from
GPs.
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218 JOURNAL OF AMBULATORY CARE MANAGEMENT/JULY–SEPTEMBER 2012
Figure 1. Schematic representation of the NHS or-
ganizational structure in England. GP indicates gen-
eral practitioner.
by Strategic Health Authorities and are regu-
lated by Monitor (an economic regulator) and
the Care Quality Commission to monitor stan-
dards (Figure 1). Under legislative and pol-
icy reforms introduced by the new coalition
government, from 2012, general practitioner
(GP)-led Clinical Commissioning Groups will
begin to take over this role (Department of
Health, 2011).
North West London is a very compact geo-
graphic region with high population density.
The population is one of the fastest grow-
ing in the United Kingdom, with an increase
of nearly 10% between the 1991 and 2001
censuses. Affluence and deprivation coexist
in this extremely varied urban region. Unem-
ployment is high in some communities, along-
side poor housing and low income, making
this one of the most socioeconomically di-
verse communities in the United Kingdom.
As a result, there are areas of severe social de-
privation and major health inequalities. Fur-
thermore, the Index of Multiple Deprivation,
published by the Department of the Envi-
ronment, Transport and Regions, shows that
more than 10% of electoral wards in some of
the PCTs in the sector fall within the 10% most
Figure 2. Schematic map of the North West Lon-
don Cluster divided into the Inner London (Ham-
mersmith and Fulham, Kensington and Chelsea,
and Westminster PCTs), Outer London (Hillingdon,
Ealing and Hounslow PCTs), and the Brent-Harrow
PCT. PCT indicates primary care trust.
deprived wards in England. Health status
across this region is also as varied as the
population, with significant inequalities in life
expectancy and disease prevalence between
specific ethnic groups. The area of NWL is
characterized by a higher than average preva-
lence of chronic diseases such as diabetes
for some ethnic minority groups, which com-
prise 35% of the population (mainly of Indian
subcontinent and African Caribbean origin).*
The NWL sector commissioning cluster
(NWL Cluster) is a partnership of 8 PCTs†
serving a population of 1.9 million (NWL
Cluster, 2010). The cluster oversees the
strategic direction of the PCTs, ensuring
that there is commissioning consistency both
throughout the sector and with overarching
regional strategic goals established by NHS
London, the Strategic Health Authority. NWL
Cluster is further divided into the Inner Clus-
ter (Hammersmith and Fulham PCT, Kensing-
ton and Chelsea PCT, and Westminster PCT),
the Outer Cluster (Ealing PCT, Hounslow PCT,
and Hillingdon PCT), and a joint Brent and
Harrow PCT cluster (Figure 2).
*North West London Diabetes Research Network (avail-
able at: http://www.ukdrn.org/lrn_nwlondon.html).
†Hillingdon, Harrow, Brent, Ealing, Kensington and
Chelsea, Westminster, Hounslow and Hammersmith, and
Fulham.
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LWW/JACM JAC200183 May 27, 2012 16:0
The North West London Integrated Care pilot 219
Hospital, or foundation trusts, provides
acute care or secondary care in the NWL
area. These autonomous or semiautonomous
secondary care providers provide services
funded by NHS resources derived from com-
petitive contracts won from commissioning
PCTs. There are 6 separate acute care trusts
serving the NWL area,* with community ser-
vices and mental health care services also serv-
ing the population. General practitioner prac-
tices provide primary care services and, sim-
ilarly, are funded by NHS resources derived
from PCT primary care contracts—these are
based on a mixture of per capita funding, ad-
ditional service reimbursement, and payment-
for-performance incentives, such as the Qual-
ity and Outcomes Framework (Gillam &
Siriwardena, 2011).
Shifting expenditure from expensive acute
care trusts to cheaper primary care and com-
munity services for conditions that are best
managed out of secondary care (NHS London,
2008, 2010) has been identified as a strategic
priority. This is for at least 2 reasons– first, as is
the case throughout England, the NWL sector
is faced with a tough financial climate over the
next 5 years, with only 0.01% increase in real
terms growth in health care funding (Richard
Jeffrey, Director of Finance, NWL Cluster, per-
sonal communication, December 6, 2011).
Most PCTs are undergoing a period of restruc-
turing to achieve necessary cost-savings as a
direct result of the economic downturn in the
United Kingdom and the recent NHS reforms
(Department of Health, 2011; Greaves et al.,
in press). Second, the flagship policy of the
Conservative party’s election manifesto - the
“Big Society”†— emphasizes the community
provision of services. The challenge for the
commissioning cluster is to achieve this with-
out alienating or jeopardizing the financial vi-
ability of acute care trusts.
The ICP is situated within the Inner NWL
Cluster (including Ealing PCT and Hounslow
*These are Ealing Hospital NHS Trust, North West London
Hospitals NHS Trust, West Middlesex University Hospital
NHS Trust, Hillingdon Hospital NHS Trust, Imperial NHS
Trust, and Chelsea and Westminster NHS Trust.
†The Big Society is available at: http://en.wikipedia.org/
wiki/Big_Society.
PCT) and involves the corresponding local
authorities, 2 acute care trusts (Imperial
NHS Trust and Chelsea and Westminster
NHS Trust), 3 community health care trusts,
2 mental health care trusts, and voluntary
sector organizations (Table 1). Within this
sector, 106 GP practices have signed up for
the pilot program.
The ICP design originated from discussions
among NHS London and the NWL Cluster Di-
rector of Strategy with acute care trusts and
leading GP providers (Scott Hamilton, Op-
erations Director, Integrated Care Pilot, per-
sonal communication, December 6, 2011).
The shared imperative is to enable a 2% re-
duction in total health and social care spend-
ing on the pilot population and a movement
of this spending from secondary care services
in acute care trusts to the non–acute com-
munity services, that is, primary and social
care (£23.1 million of activity over 5 years)
while maintaining or enhancing access and
quality of care. It is anticipated that through
improved coordination of care between pri-
mary and secondary care providers, around
7 hospitalizations may be avoided per 2000
pilot registered population. Resources (£4.3
million) have been applied on the basis of a
calculated overperformance (ie, excess hospi-
talizations), relative to 2008-2009, and it has
been implemented in principle on a “pilot”
basis over 1 year (June 2011-May 2012). Plans
are already being laid for it to be replicated
in the Outer NWL Cluster of PCTs and for the
NWL ICP to incorporate more patient groups
other than people with diabetes and elderly
population and over an additional 1 to 2 years.
In the following sections, we describe the
core interventions used by the ICP to improve
coordination of delivery of care for its current
target population, people with diabetes and
elderly patients, and we consider its unique
governance and finance arrangements.
CORE INTERVENTIONS
Information technology tool
A purposively designed information tech-
nology platform is one of the main interven-
tions of the ICP. Before the ICP, patients’
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220 JOURNAL OF AMBULATORY CARE MANAGEMENT/JULY–SEPTEMBER 2012
Table 1. Partner Organizations in the North West London Integrated Care Pilot
Commissioners Voluntary Sector Providers
Region/Cluster Age UK Social Care Services
NHS London Diabetes UK Hounslow
North West London Cluster Ealing
Local Kensington and Chelsea
Hounslow PCT Hammersmith and Fulham
Ealing PCT Westminster
Kensington and Chelsea PCT Primary care and community care
Hammersmith and Fulham PCT Central London Community Healthcare
Westminster PCT Hounslow and Richmond Community
Healthcare
Local authorities Central North West London Community
Healthcare
Hounslow General practices (n =106)
Ealing Secondary care
Kensington and Chelsea Imperial College NHS Trust
Hammersmith and Fulham Chelsea and Westminster NHS Trust
Westminster West London Mental Health Care Trust
Central and North West London NHS Trust
Abbreviations: NHS, National Health Service; PCT, primary care trust.
medical and social care records were stored
in different locations with different provider
organizations. This made it difficult to iden-
tify high-risk patients and coordinate decision
making across providers. The ICP IT tool en-
ables collaborating partner organizations to
share, manipulate, store, and analyze patient
data. Specifically, the IT tool enables the ex-
traction of patient data, performance manage-
ment, referral support, and care planning and
risk stratification. Data from GP, hospital, so-
cial care, and community and mental health
care systems are combined into a secure cen-
tral database where episode planning, medical
information sharing, and performance evalu-
ation takes place. These data are used to risk
stratify patients on the basis of their individ-
ual medical and social characteristics, against
their likely need for unplanned hospitaliza-
tion. This is carried out at GP practice level,
using the combined predictive model (CPM)
tool, a validated predictive model developed
by the King’s Fund (2006). In addition, the
ICP developed a second stratification model
to be used in conjunction with the CPM for
people with diabetes and is based on Quality
and Outcome Framework indicators, that is,
patients are identified who are not meeting
nationally recognized clinical targets or clini-
cal measures based on guidelines. Risk stratifi-
cation guides practitioners in developing care
plans for the pilot population. The IT tool also
has an e-mail function connecting GPs and
acute care consultants, enabling streamlined
communication pathways and referral. Local
service providers are “mapped” on to the IT
tool to facilitate referral and to support iden-
tification of the services that might be bene-
ficial for particular patients. All providers are
able to access the IT tool and can see recent
outpatient appointment times and risk scores
for each patient and record patient care activ-
ities for their own or other provider organiza-
tions. Pathology results will also be accessible
to all ICP partners, and ambulance and other
emergency service providers will be able to
identify patients who are part of the ICP and
liaise with community services to avoid hos-
pitalization where possible.
Both access to and use of the IT tool are gov-
erned by a legally binding information shar-
ing protocol. The protocol is an overarching
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LWW/JACM JAC200183 May 27, 2012 16:0
The North West London Integrated Care pilot 221
agreement between the ICP partners to
regulate the sharing of specific person identi-
fiable information between themselves for the
delivery of care for diabetes patients and older
adults. The protocol specifies which kinds of
data can be extracted and the purposes for
which it can be used. This is important be-
cause between the acute care and primary
care providers, there are no fewer than 10
different IT systems in use across the NWL
sector.*
Multidisciplinary group meeting
The second intervention designed to im-
prove integrated ways of working is the use
of MDG meetings involving ICP provider or-
ganizations, that is, GPs, hospital specialists,
mental health care, community nursing, social
care, and other allied health care profession-
als. Before the ICP was implemented, there
was no way to obtain a single, unified view of
a patient’s care and his or her journey through
the health system. The MDG meetings bring
these different health care professionals to-
gether to discuss the care of those people
(with diabetes or older than 75 years) with
the most complex needs—with a view to im-
proving care planning and its coordination.
Care plans are established and agreed upon
by the participating professionals, and imple-
mentation of the plans can be monitored and
guided through the IT tool.
Multidisciplinary group meetings are con-
stituted by a legal process—this enables re-
source plans to be approved, governance
structures to be clarified, data to be extracted,
care plan templates to be approved, and pa-
tients to be invited to discuss the care plans.
The process takes around 2 months to com-
plete. Multidisciplinary group meetings are
chaired by GPs and are managed and run by
MDG coordinators whose role is to (1) de-
velop effective and collaborative relationships
with members of the MDG; (2) be the first-line
contact point for stakeholders and establish
systems and processes that will ensure timely
*These include Prowelness, EMIS, System One, Rio, SuS,
CNWLHT and WLMHT, Adastra, EDC, and ICH A +E.
and appropriate response to queries from clin-
icians, patients, public, and other stakehold-
ers; and (3) to work with MDG members to
identify areas where there are bottlenecks in
the clinical pathway and undertake process
mapping to effect a solution.
There are 9 established MDGs each at differ-
ent stages of incorporation (Table 2). Consid-
erable flexibility is built into the MDG oper-
ations to allow for local-level variations, for
example, within their defined resource en-
velopes, MDGs can determine how to allocate
resources to care planning, out-of-hospital
projects, case conferences, and performance
reviews. Finally, any material decision made
by an MDG relating to its operation or ways
of working must be agreed by all members
of that MDG; however, MDGs can decide
whether this is by a consensus or majority
vote.
Governance
Given the multiplicity of organizations that
collectively comprise the local health econ-
omy in NWL, and the need for interagency
working within the pilot, governance arrange-
ments have been crucial. A collaborative ap-
proach such that interests and concerns could
be shared in an open and transparent forum
has been adopted. The ICP is governed by an
unincorporated association of the ICP part-
ners chaired by an independent chairperson
and bound by the requirements and stipula-
tions of a legally binding Establishment Agree-
ment. The ICP board, called the Integrated
Management Board (IMB), is composed of se-
nior representatives (usually the chief execu-
tives) of collaborating organizations. Voting
rights reflect the membership, that is, 50%
GPs, 25% acute care providers, 10% third
sector representatives, 5% community health
care providers, 5% local authority providers,
and 5% mental health care providers. This has
been designed to ensure agreement around
funding flows, to allow access to the IT tool
and arrangements for data sharing among the
ICP partners, and to permit mutual account-
ability and collective decision making. The
IMB cannot be a committee of any ICP partner
or any combination of the ICP partners, and
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222 JOURNAL OF AMBULATORY CARE MANAGEMENT/JULY–SEPTEMBER 2012
Table 2. Multidisciplinary Groups in the North West London Integrated Care Pilot
Practices “Live”a
PCT MDG
GP
Practices
Registered
Population
Diabetic
Persons Elderly First Last
Westminster CLH 13 64 000 2 700 3 400 Sep 23 Oct 14
Victoria 8 48 000 1 200 2 600 Oct21 Oct21
Hammersmith
and Fulham
H+F
Central
5 40 000 1 100 1 800 Nov 4 Nov 11
H+F
North
Central
9 72 000 2 100 2 500 Oct 7 Nov 4
H+F
South
Fulham
6 38 000 700 1 700 Oct 7 Nov 4
Kensington
and Chelsea
K+C
North
17 74 000 2 100 3 400 Sep 23 Oct 28
K+C
South
17 73 000 1 700 36 00 Sep 23 Oct 28
Ealing Acton 12 55 000 1 600 2 600 Pre-Sep Oct 7
Hounslow Chiswick 9 42 000 1 000 2 200 Oct 7 Oct7
Total 93 506 000 14 200 24 200 Sep 23 Nov 11
Abbreviations: CLH, Central London Healthcare; H +F Hammersmith and Fulham; GP, general practitioner; K +C
Kensington and Chelsea; MDG, multidisciplinary group; PCT, primary care trust.
a“Live” is defined as when the IT tool has been incorporated into GP practices and users trained in its use.
each ICP partner and IMB member remains ac-
countable to and bound to act in accordance
with its own organizational governance
arrangements.
Implementation and conduct of the ICP are
delegated to the IMB operations (Ops) team.
The Ops team is “hosted” by one of the part-
ner organizations, the Central London Com-
munity Healthcare Trust, under the terms of a
hosting agreement. The Ops team comprises
health care managers and MDG coordinators
with responsibility to oversee the implemen-
tation of the ICP. Between the Ops team and
the IMB are several subcommittees (evolved
from the early working groups that were es-
tablished to design the ICP): Clinical and Edu-
cation, Finance and Performance, Evaluation
and Research, Information Technology, and
Patient Groups. These subcommittees also
have a mixed membership from all ICP part-
ners and are always cochaired by a represen-
tative from an acute care trust and a lead GP.
Participation in the subcommittees is open,
and a member of the Ops team always attends
the subcommittee meetings.
The IMB has some very specific shared func-
tions as laid out in the Table 3.
Finance
There are 2 key issues in the ICP, involv-
ing the acute care trusts and the GPs. First
of all, acute care trusts are only reimbursed
30% of the value of any unplanned admission
that exceeds an agreed quantity (the so-called
overperformance). While they have an incen-
tive to reduce this activity as much as possible,
the diversion of activity from the acute care
trusts into the community represents a threat
to hospital income. Second, from the primary
care perspective, traditional referral practices
have reduced the coordinating role of GPs in
caring for patients with complex needs. Par-
ticipation of GPs in and coordination of MDG
meetings is considered to be an additional ac-
tivity that requires incentivizing. It is impor-
tant to align these interests and issues with
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The North West London Integrated Care pilot 223
Table 3. Roles and Responsibilities of the Integrated Management Boarda
Approval and removal of ICP partners
Approval of new MDGs
Approval of resource plans and supplementary resource plans submitted by MDGs
Creation of and adjustment to payment schedules in accordance with approved resource plans and
supplementary resource plans and approval of payments under the same from out-of-hospital
funds
Approval of allocation of infrastructure funds and of connected contractual relationships
Oversight of hosting arrangement
Provision of assistance in negotiation if the IMB deems it necessary of contractual arrangements
within MDGs and between MDGs and commissioners
Approval of amendments to the MDG rules and contractual documents
Review and, as necessary, amendment of the MDG operational guide
Monitoring implementation of the information sharing protocol and reviewing its terms
Approval of any changes to the design of the ICP
Approval of proposals for any ICP evaluation and approval of such completed projects for
publication
Monitoring outcomes from the ICP and overseeing performance
Approval of the release of Reinvestment funds in accordance with the memorandum of
understanding
Appointment of an auditor of the ICP
Approval of the continuation of the integrated care program beyond the ICP
Abbreviations: ICP, Integrated Management Board; MDG, multidisciplinary group.
aDerived from the Establishment Agreement.
the broader policy and finance imperatives.
Broadly, therefore, 2 key financial strategies
have been employed in the ICP to take into
account the interests of the acute care and
primary care providers.
First, all ICP partners will receive a propor-
tion of any funding surplus at the end of the pi-
lot. The target is to reduce hospital admissions
by 16.2% (1771), and once the ICP is cost neu-
tral, any surplus is shared with all partners.
The commissioning NWL Cluster would thus
receive 50% and the remaining 50% is divided
between the acute care trusts and the other
partners. Of this 50%, the acute care trusts
would receive 25% divided equally between
Imperial NHS Trust and Chelsea and West-
minster NHS Trusts; 50% would go to the 10
MDGs and their component GP practices di-
vided according to their population size. The
remaining 25% is divided between community
care (5%), social care (5%), mental health care
(10%), and user groups (5%). For any member
to get the incentive, admissions have to be
reduced overall rather than if one MDG does
well compared with the others. It is recog-
nized that attributing causality to any drop
in hospital admissions is complex and one of
the objectives of the ICP evaluation is to un-
pack some of that complexity. However, the
commissioning NWL Cluster has agreed that
50% of any drop in hospital admissions will
be attributed to the ICP because it is the most
developed initiative occurring in the region.
Importantly, this applies also to any liabilities
incurred at the end of the pilot period (Scott
Hamilton, Operations Director, personal com-
munication, December 6, 2011).
The second financial strategy is a resource
envelope available to each MDG for delivery
of the care planning, case conferences, and
performance reviews. This envelope is calcu-
lated at £40 per person with diabetes and £80
per elderly patient registered in the associated
general practices. The ICP allows for consid-
erable flexibility around how the resource en-
velope is allocated, and in addition to fund-
ing predetermined actions and activities, it
also includes an out-of-hospital contingency
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LWW/JACM JAC200183 May 27, 2012 16:0
224 JOURNAL OF AMBULATORY CARE MANAGEMENT/JULY–SEPTEMBER 2012
“pot” that can be used to pump prime new
service developments identified as needed by
the MDG. All costs incurred are reimbursed
and audited internally and externally.
DISCUSSION
Integration within the context of organiza-
tion of health and social care is a multidimen-
sional construct and it can be implemented
to varying degrees (Leutz, 1999). Dimensions
of integration include function (Fulop et al.,
2005; Lewis et al., 2010), direction (Lewis et
al., 2010; Shaw et al., 2011), and intensity
(Ham et al., 2011; Lewis et al., 2010; Rosen
& Ham, 2008). The summary of integration
typologies of Lewis et al. (2010) explains that
it can occur in organizational, functional, ser-
vice, clinical, normative, and systemic forms.
On the basis of these typologies, the ICP
can be described as addressing organizational,
functional, service, and clinical types of inte-
gration. The ICP involves a brokered, contrac-
tual agreement between different provider
organizations via a purchaser (NWL Cluster);
nonclinical, back-office functions are inte-
grated through the IT tool; some clinical
services, in particular care planning, are de-
veloped through MDGs; and clinical care has
become more consistent and coherent
through the use of shared and agreed clinical
pathways and guidelines.
However, there are several challenges, not
only due partly to the program itself and its de-
sign but also due to the challenges of integra-
tion broadly defined. First, MDGs are driven
by and located in primary care services with
acute care trusts covering several MDGs each.
Consequently, there is a considerable time
burden for the secondary care specialists who
participate in several MDGs per month. This
may lead to inequities in service provision at
the secondary care level. Second, although the
IT tool integrates a considerable amount of in-
formation from multiple data sources, local
users such as GPs are required to interface
with the new IT platform as well as all the
other different platforms already in operation.
This could put considerable time pressure on
the users and increase duplication of data en-
try. Third, the MDGs represent an opportunity
through clinical case discussion for partici-
pants to identify barriers and challenges in the
broader local health economy that together
could be resolved through open discussion
and shared experience. However, it is unclear
whether the MDGs will achieve this kind of in-
tegrating perspective in their case discussions
and may vary considerably from one MDG
to another. Multidisciplinary groups may, for
example, simply replicate traditional commu-
nication and referral patterns that reflect en-
trenched relationships between GPs and spe-
cialists. Fourth, there are already plans under-
way for the ICP to be expanded into other clin-
ical domains, other than diabetes and elderly
care, such as chronic obstructive pulmonary
disease, mental health care, and pediatric
care. The risk here is that while care coordina-
tion may be shifted into the community, it may
still replicate preexisting clinical domains.
Finally, integration is commonly under-
stood as a shift away from traditional, hi-
erarchical health services based on clinical
disciplines (Shaw et al., 2011). The ICP is de-
signed to avoid duplication in clinical care,
eliminate some of the day-to-day frustrations
in care delivery, for example, lack of access
to full patient information, and bring a new
mutual accountability to the patient path-
way, not merely the episode of care, and
it is a managed transition from costly sec-
ondary care to community care. This alone
is a considerable achievement and the ex-
periences have in many ways already been
positive ones. However, integrated care is re-
ferred to when improved integration benefits
patient groups (Kodner & Spreeuwenberg,
2002), and it is not clear yet whether and how
the ICP will achieve this. While the ICP inte-
grates the coordination of clinical care, the
clinical care itself remains much the same,
with patients receiving that care in the same
services.
CONCLUSION
We have described in detail the key
interventions in the NWL ICP —a bold
and ambitious program involving substantial
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

LWW/JACM JAC200183 May 27, 2012 16:0
The North West London Integrated Care pilot 225
organizational change in a complex health
economy. Although in its early stages, the ICP
has achieved significant momentum and co-
ordination. There is some indication that the
use of pooled incentive structures for both
acute care and primary care partners, multidis-
ciplinary team meetings, and a collaborative
governance structure where responsibility is
shared among commissioners and providers
has facilitated improved partnerships. There
are therefore already some interesting lessons
for health care planners working in similar
contexts. In future work, we will evaluate
the impact of the ICP on clinical outcomes,
cost-effectiveness, and patient and profes-
sional experience and develop lessons that
can be applied by other areas in England
that are considering the development of in-
tegrated care program, and lessons for health
systems in other countries.
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