Making Integrated Care Systems Happen

Integrated Care in both the NHS and internationally is emerging as a major service and structural means of transforming quality and efficiency in health and social care. The proposals for Integrated Care Systems (ICS) published to-date describe a dynamic, transformational programme for improving both quality and efficiency across NHS health and social care.

We have developed a set of Papers/Guidance Notes on 6 key aspects of Making Integrated Care Systems Happen. They are designed to help senior clinicians and managers working on ICSs to move to the next phase. Each Paper is available to download below

1. Service Design and Delivery

Paper 1.  Service Design and Delivery draws upon information derived from an analysis of population health needs, engagement with the community and identifies the potential for redesigning patient flows across the system and community. It consider how service requirements are to be identified and modelled including ICS-wide acute services, integrated care and advanced primary care and located in each specific Place.

Download Paper 1. Service Design and Delivery here

2. Putting the Resources Required in Place

Paper 2. Putting the Resources Required in Place: Workforce Finance and Estate focuses on these key enablers in an ICS and how these should be developed to best effect. Since integrated care below the level of organisational structures  implies a transformative system of care delivery,  we are very clear that the time is ripe to integrate workforce development and requirements planning into service, capacity,  and financial planning.    

We concur with NHS confederation observation that “poor implementation is a more common cause of failure of reform than poor design.'(2011) and set out how agreed measures are to be progressed with detailed implementation planning.

These are areas where we have specialist expertise and experience, and where in partnership with clients and our international collaborators we are able to accelerate the mechanisms to secure change.

Download Paper 2. Putting the Required Resources in Place here

A supplementary Paper 2.1 Best Practice in Workforce Development draws upon a new commission that we were asked to undertake by the World Bank in 2020/21. This required us to conduct an evidence review on best practice internationally on healthcare human resource planning and management. Drawing on evidence from  OECD countries we documented many examples of good practice that we found. The one crucial element of workforce development that falls short however, is requirements planning. This Paper offers detailed guidance and methodologies in workforce  planning as an aid to all organisations facing this particular challenge.

Download supplementary Paper 2.1 Best Practice in Workforce Development here

3. Organisational Development

In Paper 3. Organisational Development we provide a working definition of the key components of an Integrated Care System (ICS). This draws on the prescriptions of current NHS England guidance and frameworks plus the findings from concurrent evaluation of the Pioneer ACOs in the US.  The most successful US pioneers have transformed quality of care whilst also reducing hospital utilisation and thereby containing costs. Finally, in the main body of the document we list the key components of success and propose practical solutions for implementing  each of these components.

Download Paper 3. Organisational Development here

4. Population Health Management

In Paper 4 Population Health Management we look at how whole population health management can progress the objectives of Integrated Care Systems to extend integrated, pro-active out-of-hospital care and mitigate hospital utilisation. The approach we propose draws on current practice both within the NHS today, and international models that are delivering triple-aims outcomes today. 

Download Paper 4. Population Health Management here

5. Care Co-ordination

Paper 5 Care Co-ordination focuses on more pro-active care for people with long-term conditions that is core to the ICS model.  People have differing levels of needs and thus need personalized support from health and social care. Conrane IHS has developed a toolkit to model the impact and guide the delivery of care coordination within a locality based integrated care system. This Paper draws on our experience of implementing effective models that deliver improved quality of life for patients, better value for money and staff satisfaction 

Download Paper 5. Care Co-ordination here

6. Applied Intelligence

Paper 6 Applied Intelligence considers how we can use best in class health informatics tools to improve service delivery and our understanding of changing population health needs at various levels – from that of the individual to the General Practice level through to the whole health community.

Adjusted Clinical Groups (ACGs) ® were developed by the late Professor Barbara Starfield with her colleagues at Johns Hopkins University School of Public Health over more than 30 years as a primary care workload and case management tool, the ACG System is now the international market leader in population risk profiling and is in use across the World.

The ACG System is a suite of tools which draw on demographic, diagnostic, pharmacy and utilisation data from primary and secondary care. The primary care utilisation data includes GP attendances, prescribing, diagnostics, and referrals; secondary care includes admissions, bed days, A and E attendances. From this combined data base, several case mix or risk measures can be derived – both current and prospective. These begin with the individual patient and then are aggregated to each GP list, to practice level, and to whole health community levels. The ACG System has several applications that support evidence based commissioning and service delivery.

Predictive models identify individuals and groupings within a population who are expected to be high utilisers of health care resources, predominantly people with long-term conditions. Population risk profiling is defined as the process by which the health status of a population is measured for planning services, equitable budgeting, resource management and assessing outcomes. The ACG System is designed to meet all of these needs from one data set and one clinically-inspired analytics tool.

Predictive modelling is a key stage in long-term condition (LTC) management which improves quality and patient satisfaction, but also reduces both secondary and primary care workload and costs. As the ACG System is primary-care based, it facilitates the close working between the LTC service and the patients’ GP which is essential to achieving these outcomes. Also if the clinicians managing the patients have regular feedback on their utilisation of service, they are more likely to show a return on investment. Such best practice models which the ACG System can support include “Guided Care” and the virtual ward.

Download Paper 6. Applied Intelligence here