Decisions that can make or break an integrated care strategy

blog | 26 Apr 2018

In 2015, West London CCG set up a new service for older people called My Care My Way (MCMW). The service was created as a response to feedback from local people which indicated dissatisfaction with the current, fragmented model of care: they wanted a new approach.

My Care My Way is a holistic system of health and social care for older people with three key elements:

• New patient-facing roles based in GP practices (Case Managers and Health and Social Care Assistants)
• Multi-disciplinary assessments (including hospital specialists) and extended GP appointments
• A whole system focus on self care and social prescribing

Three years on and MCMW is in rude health. All 44 practices in West London now have (or will soon have) an active MCMW staff team, and a recent evaluation indicates that these teams are making a real difference to non-elective admissions. In fact the service has been such a success that the model now sits at the heart of the local system’s integrated care strategy.

The ethos of prevention, self care, and holistic and person centred case management at the heart of MCMW is becoming more like business as usual across primary care. For example, over the last six months partners across West London have been codesigning a new integrated model of care. The linchpin of the model is the Integrated Community Team, whose goal is to meet as many of a patient’s needs as possible in the community, without having to fall back on expensive hospital care.

The Integrated Community Team will be made up of:

1. A series of ‘spoke’ teams made up of community professionals (including MCMW staff, nurses and social workers) working with small groups of GP practices to find patients, promote self care and actively manage the most complex cases.
2. Two central ‘hub’ teams (based out of West London’s two integrated care centres) that provide spoke teams with access to specialist consultation, input and supervision as well as population health analysis that can help to identify the most complex and high risk patients.

Spoke teams in particular will be encouraged to use the full breadth of their clinical and social expertise to deal with problems as they arise. Specialist input is easily available if required, but staff will always be encouraged and supported (through supervision and consultation) to focus on what they can do to support a patient.

West London has a long way to go before the Integrated Community Team fully becomes a reality, but the strength and clarity of the vision that drives it is admirable, as is the extent to which local partners are bought-in to the direction of travel. And this is no accident. The system in West London took two important decisions very early in their journey with integrated care that continue to shape the progress that has been made:

DECISION 1: INNOVATE FIRST, INTEGRATE SECOND.

The MCMW service has been running since 2015. When the service was originally designed, partners recognised that the principles of case management, self care and prevention should also sit at the heart of any attempt they were making to integrate services. But rather than push for more formal integration they decided to start by commissioning an innovative new service that could sit alongside existing provision, that would itself act as an integrator and over time demonstrate the value of working in this way. This resulted in a slightly messy management structure, with the CCG managing the service overall and individual MCMW staff being employed by different local providers.

Whilst this structure led to operational challenges, it gave all partners skin in the game. It also meant that integrated governance forums emerged to manage the new service, without any mention of integration. In fact the two groups that were set up to govern MCMW (the Alliance Leadership Group and the Alliance Operational Group) are now the forums that own and govern the implementation of both the integrated care strategy and the new Integrated Community Team. They have stood the test of time.

This ‘innovate first, integrate second’ approach is one that Innovation Unit has seen work elsewhere. In Lambeth, the Lambeth Living Well Provider Alliance is on the brink of agreeing a 10 year alliance contract for the delivery of all £600 million of mental health spend in the borough. For the last four years the alliance has been working together to deliver an innovative new front door to mental health services, the Lambeth Living Well Hub, which is essentially a commissioned service delivered by a multidisciplinary team, made up of seconded staff from across the system.

The process of working together to design and deliver an innovative approach (the hub in Lambeth, or MCMW in West London) creates the local conditions, and builds the relationships, upon which real and meaningful integration can be built. In particular, partners now have the trust that can only come from having worked together in practice to do something different. In parallel, both MCMW and the Lambeth Living Well Hub have developed blueprints for a new integrated care model – so neither system is starting from scratch.

DECISION 2: LEARN FORWARD, TOGETHER, THROUGH EXPERIMENTATION AND CODESIGN.

In April last year, West London CCG commissioned Innovation Unit and PPL to deliver a programme of rapid learning across nine GP practices in West London that were implementing MCMW. The aims of this programme were to:

• Test tangible and practical improvements to MCMW and how it works with other services.
• Surface and capture what makes the core MCMW model work, and share this across practices to improve quality and reduce variation.
• Develop a culture of learning, and empower MCMW staff to drive continuous improvement.

Critically, the programme of rapid learning was also designed to inform long term commissioning intentions, and in particular the development of the integrated care strategy. Through weekly learning labs in each GP practice, MCMW teams worked with colleagues to test, refine and improve the model in real time, before sharing what they learned with other practices across their patch.

The spirit of collaborative endeavour and experimentation developed through this collaborative learning approach has also underpinned the development of the Integrated Community Team. Where possible partners have tested new ideas with frontline staff and patients, using the Alliance Operational Group as the engine for experimentation and testing. A whole system codesign group has worked together to tackle all big questions related to the design of the care model and now there is broad acceptance that, whilst the principles and the high level design of the new approach will remain fixed, the model itself will flex and evolve as the newly formed provider alliance starts to take ownership.

Experimentation and codesign have also been the driving force behind the success of the Lambeth Living Well Hub. The hub model emerged on the back of 12 months of prototyping with patients and staff, and the provider alliance has worked closely with the Lambeth Living Well Collaborative (a network of local community organisations and service user groups) to develop and refine the model over time.

In both instances, the commitment to experimentation has meant that new care models,  financial projections and forward plans are collectively owned and informed by on the ground realities – they are desirable, feasible and viable, neither overly optimistic nor limited in their ambition.

Through disciplined innovation and learning, both West London and Lambeth have made real progress towards integrated care, whilst improving patient experience and delivering significant benefits to the system as a whole. We are working hard to ensure that the lessons from this work are available to the hundreds of other areas that are on the same journey. If you are one of those areas, then please get in touch.

Contact Jonny Mallinson or William Roberts for more information on our work in health and social care.

UPDATE: The success of MCMW and the programme of rapid learning (led by Innovation Unit and PPL) that has supported its development, has now been recognised by nominations for an MCA Change Management award and a HSJ Training and Development award.