A critical analysis of the Implementation of The Government Initiative – The Integrated Care and support Pioneers programme, specifically focusing on the North West London Pioneers
This assignment aims to address what is integrated care and why it is thought to be so important within healthcare. To visit a national initiative that promotes integrated care and to critical analyse this.
What is Integrated care ? and why develop this approach to care ?
Integrated care or co-ordinated care has been discussed within health care for many years and is believed to be the best approach to healthcare. It is thought to get the best outcome for patients with co morbidities, their families and the services that provide the care. Curry and Ham, (2010) support this by suggesting that the benefits of integrated care are ‘most likely to be achieved when the model is targeted at the patients most at risk of fragmented care, such as elderly and those adults with multiple health issues. These areas of care are thought to be a drain and the integration of their care would improve the patient’s healthcare journey’. This idea of integrated care was addressed by Stein and Reider (2009) who stated that ‘we now refer to as ‘integrated care’ is an umbrella term, encompassing diverse initiatives that seek to address fragmentation, but that differ in underlying scope and values’. Evidence suggests it will reduce patients being given a disjointed approach to their needs. This is presently in many areas of care leading to repetition, seeing different healthcare providers, causing delays, as well as adding to financial pressures. Kodner and Spreeuwenbur, (2002) offers that ‘without integration at various levels of health systems, all health care performance can suffer. Patients get lost, needed services fail to be delivered, or are delayed, quality and patient satisfaction decline and the potential for cost effectiveness diminishes’.
Government developments to integrate care
One of the ways in which the government has addressed this, was with the Integrated Care and support Pioneers programme a national initiative introduced in November 2013. Within this there were many differing models for integrated care, in terms of this paper the North West London (NWL) pioneers first two years will be critically evaluated. Along with theories that could be considered and how these may have aided or hindered the introduction of these care models.
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Valentijin, (2015) offers the opinion that ‘integrated primary care services are considered a vital strategy for maintaining sustainable and affordable healthcare provisions’. Since the health and Social Care Act 2012 was introduced many ways of working have been introduced to adopt integrated care. This then brought on The Care Act 2014 which then placed more pressure on local authorities to develop co-ordinated care. Alongside National voices, which was released in 2012.In which spoke it of ‘patient centred coordinated care’ and took into consideration the patients wants and needs. This was a strong driver for change and The Integrated Care and Support Pioneer Programme was announced in May 2013.
Local areas were invited to bid to be pioneers, asking them to demonstrate how they were or were planning to deliver integrated care for its local areas. The successful Pioneers were split into two waves: wave one introduced fourteen sites in November 2013 and wave two with another eleven sites in January 2015. The plan for these was to ‘pioneer new approaches to provide care and support which is coordinated to people’s needs’ NHS England, (2015). Each was provided with funding to assist their projects, as well as sponsor from a national partner agency. These pioneers were planned to become figure heads for the rest of the Healthcare system and develop New models of care.
North West London
One of the first fourteen pioneers chosen was NWL project, this was a huge project, it planned to involve eight boroughs. It was to encompass over two million people and according to NHS England, (2015)’ The scale and complexity of transformation in NWL is almost unprecedented in the history of health and social care in England’. Not only due to the large population but due to the diversity of the people within those boroughs, who had differing needs in terms of culture, affluence and health. The large number of Clinical Commissioner Groups (CCGs) and General Practitioners (GPs) led this to be thought of a large system transformation. Best et al. (2012) offers that ‘Large‐system transformations in health care are interventions aimed at coordinated, system wide change affecting multiple organizations and care providers, with the goal of significant improvements in the efficiency of health care delivery, the quality of patient care, and population‐level patient outcomes’, which fits the NWL model well.
NWL was well into its planning stage when it applied for Pioneer status and that’s what led to the decision to encompass so many more boroughs in the pilot. It planned to address integrated care for the elderly and adults with one or more health conditions. NWL had already had previous success with their integrated care pilot in November 2011, where they had won a Health Service Journal award for their work on improving care for the over 75s and patients with diabetes. It aimed to build on this and reduce hospital admissions and keep patients in control of their own care alongside their G.Ps. They planned to do this by giving the patents a ‘single point of contact who would work with them to plan all aspects of their care taking into account all physical, mental and social care needs’ Department of Health and social Care ,(2015).
Co-design and early Adopters
After NWL had achieved this status it was decided the project needed to be broken into phases, first being of a process of co-design and then move to a first adopters’ stage. During the co-design stage many were consulted such as ‘health and social care organisations, patients, other service users and carers from across NWL. These were invited into working groups to develop solutions to common challenges to the design and delivery of integrated care’, Nuffield Trust, (2013).
Due to NWL’s history of working together, this allowed them to easily invest time into gathering interest develop strategic planning and joined vision, as links had already been made. The vision needed to be embedded, so during the co-design stage ‘Lay partners’ were asked to get involved. This would give the project a diversity of opinions and ideas across the boroughs. These ideas for new ways of working and models of care were explained in the Whole system Integrated Care toolkit which was developed and released in May 2014. This toolkit was the coming together of over 200 individuals and organisations across NWL, sharing their knowledge and the development of ideas of how to implement whole systems integrated care. (North West London CCG, 2018).
All the areas within NWL were invited to bid to be early adopters, the learning that would be gained from these adopters would then be developed and refined further to then implement the New models of care to the rest of the population. The adopters were given high level of support to ensure that they shared the vision of joined up care, but they would face their own local problems individually.
The Nuffield Trust and the London school of Economics and political science were asked to evaluate the North West pioneers from February 2014 to April 2015. This gave huge insight into how this particular project was fairing, they gathered their data from meetings, observations, focus groups and surveys of the early adopter steering committee members and the GP practices involved. This highlighted many positives in these early stages of. Smith, Gaskin et al. (2015), who were involved in the Nuffield trust evaluation, stated that they ‘found North West London approach to developing integrated care was large scale, ambitious and very well resourced’.
Analysis of Co-design phase & Early Adopters
Evidence suggests this was a strong phase and that within this time from multiple working groups that met regularly, with the overseeing ‘Embedding Partnership group’, this was governed by the lay partners. (Morton and Paice, 2016). Smith, Gaskin et al. (2015), (2015) believed this phase to be ‘one of the programmes defining characteristic’s’. This was backed up by Sawell, (2015) who was quoted by Timmins, (2015) that one of the factors of success in NWL had been genuine co-design with lay people. Timmins, (2015) offered that ‘Involving patient, service users and carers is vital because they help identify which elements of service redesign are needed’ which is what NWL achieved.
But evidence showed due to the long co-design and adopter stage ‘there could be risk these patients, service users and carers, could become frustrated and question the purpose of their involvement’ Smith, Gaskin et al. (2015), Through the qualitative data gathered by Smith, Gaskin et al. (2015), it was determined that the enthusiasm was particularly high at senior level, but there was ‘a relative absence in the co-design phase of frontline staff, including social workers and community Nurses’. They also went on to uncover that even though there was a core group of G.Ps that felt highly motivated there was also a group that felt unaware and distant from the pilot. Sawell,(2015) cited in Timmins, (2015) who is the Director of Strategy and Transformation for NWL Collaboration of CCGs, when questioned stated that ‘7 of the 8 councils supported the integration project, so they worked with irregular geometry, you work together where it makes sense and then you don’t where it doesn’t or cant for the time being’. This could give the explanation of the evidence uncovered by Curry, Harris et al. (2013) that participants felt that multidisciplinary groups were not producing a ‘significant cultural shift in ways of working’. Senge, (2015) also stated that ‘Yet more often than not they have floundered—in part because they failed to foster collective leadership within and across the collaborating organizations.
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This has been considered to be a ‘Top down approach’ offered by Sabatier and Mazmanian, (1979) cited by Cerna, (2013) which as Matland, (1995) who was also cited by Cerna, (2013) offers it allows ‘consistent recognisable patterns in behaviour across different policy areas’ to be adopted and used, but of course as above suggests the frontline staff are not taken into consideration When considering these approaches and what NWL carried out in their co-design phase you could also reason that the bottom up approach was adopted by using the lay partners. As Matland, (1995) offers ‘Bottom-up designers begin their implementation strategy formation with the target groups and service deliverers, because they find that the target groups are the actual implementors of policy’, but as equal to the top down approach the bottom up had disadvantages such as ‘policy control should be exercised by actors whose power derives from their accountability to sovereign voters through their elected representatives, but authority of local deliveries does nor derive from this’ Matland, (1995). Therefore, it could be suggested that if a systems leadership approach was adopted then these disadvantages could have been avoided. ‘System leadership has become less of a nice to have and more of a must have’ (Timmins, 2015). He then goes on to offer the explanation of system leadership as a collective leadership and that for the NHS to adapt and develop they must move towards this belief ‘that leadership is the responsibility of teams and needed at all levels’.
From what Sawell, (2015) cited in Timmins, (2015) states ‘ the 8 CCGs have been ahead in thinking about how, without giving up their sovereignty, they can see benefits from working together. The chairs had worked together as clinical leads in the PCTs for longer than in many other places. They were used to working together, on leading Shaping a healthier future’. NWL had started to adapt to a systems leadership approach but this does have its disadvantages as offered by Timmins, (2015) ‘it is not easy, It takes time, its starts with the collation of the willing, patients and carers are crucial in helping design the change. As visited, this certainly echoes the challenges and the practices of what NWL had carried out and come across.
It was found that the early adopters were encouraged to take time and resolve any problems, it did have an effect of pushing the timescales back. In fact Smith, Gaskin et al. (2015), found the early adopter to be 15 months behind planned timescales. Wistow, (2016) found that the move from planning to implementation of the early adaptors ‘far more troublesome than anticipated’. He stated that ‘the programme struggled to find balance between collective leadership and local autonomy, NHS leadership and local authority engagement to name a few’. (Wistow, 2016). Moving on from the co-design phase Nuffield Trust, (2013) research suggested that the gap between the G.P’s feeling involved and distant had been more aligned in the adopters phase. They were also very positive about the WSIC toolkit.
The complex adaptive theory could be offered here as Best et al. (2012) discusses how this fits a Health system when approaching integration as it ‘seeks to draw out and mobilize the natural creativity of health care professionals to adapt to circumstances’. Healthcare could be thought of as a Complex Adaptive System as it is ‘constantly adapting to its environment’ (Encourage, 2010). But there are disadvantages to this theory as Best et al. (2012) offers that ‘successful action is less about meeting target and more about shifting the systems behaviour’ This of course is not method modern Healthcare can approach easily due to funding and other National initiatives that seek performance targets to be met for patient pathways, such as the cancer waiting times, ED and GP waiting times.
But NWL did make improvements Curry et al. (2013) also evaluated NWL and when looking at the patient experience found great support. Those asked were in favour of integration and 65% who have a care plan felt involved. Of course, there were some that didn’t know they had a care plan or that they were even involved in the pilot. Mastellos, Gun, et.al. (2014) suggest that ‘listening to the views of the patient can help policymakers and clinicians develop pathways that meet patients’ needs and enable the, to provide high quality integrated care’.
Another explanation for the barriers to move from the adopters into true implementation was also the approach to budgets in primary care. They felt this could be achieved by a capitated or whole population budget approach. NHS Improvement, (2017) suggests ‘it is an effective and practical way of implementing integrated care model’. But this approach has had issues and could lead to problems. As evidence suggests from past integrated care projects that used such a model such as the Alzira project. A capitated budget has its disadvantages as the budget is forever shifting between primary and secondary care and leading to loses. But the Alzira project does work differently to NWL in terms that North west is primarily using this budget for primary care. This payment approach is still being developed NWL has one of the largest pooled budgets out of the pioneers due to the CCG’s involved. Changing the way the services are budgeted could be possible as coordinated care would reduce duplication and streamline care given.
Another area that used a similar model to NWL was Odense in Denmark like NWL Odense was well financed, excellent organisation but failed at the clinical implementation. As highlighted in Buch et al. (2018) ‘Odense and London shared an aligned governance structures, increased patient involvement and improved coordination between services’. Like London they also had a large pooled budget due to the area covered. Unlike London Odense planned to go from planning stage to wide spread role out. Buch et al. (2018) suggests ‘this was partly due to time constraints due to the limited span of time in which the partnerships had permission to share data across areas’. This differed from NWL where that did have the ability to extend the co design phase and the early adopters to ensure all issues were managed and worked out before the projects were to be widely implemented. There was though a feeling of ‘top down’ which was felt in the NWL project and that there was not autonomy as Buch et al. (2018) found in his study ‘Too many participating Doctors found this process undermined their motivation to committed to the project’. The lessons learnt from Odense did highlight the same positives as NWL in terms of patient experience and all patients involved had a clear understanding of what the aims were. Buch et al. (2018) did in fact argue that with ‘Hindsight it was unwise to copy NWL before it was properly evaluated’ and in actual fact ‘English evaluations had in fact identified a number of the same challenges Odense had faced.
Many aspects can be taken from the NWL pioneers, due to the over running of the pioneers project Curry et al. (2013) did offer that it was too early in the implementation to see a ‘major impact on service use specifically as a result of the changes in care management and coordination’. At the time Nuffield’s evaluation was ending it was becoming apparent that some of the barriers that had been experienced from national agenda were starting to think along the same lines as NWL. Therefore the evidence weighs heavily towards even though the NSL was not as successful in its implementation during its time as pioneers, the co –design and early adopter phases were the necessary stepping stones to build a new care model As Sawell, (2015) cited in Timmins, (2015) suggested ‘sometimes your planning can become so perfect that you never move onto that messy bit called implementation’. The author of this assignment recognises that this critical reflection was only on the early stages of NWL since then it has carried on with its Integrated care model. NWL has offered much learning from its Co-design and adopter phase and other projects have used this model, it has also offered how different theories to integration and leadership have had an affect on implementation as well as the barriers offer by national agenda.
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