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Collaborate and integrate

Collaborate and integrate

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Clinical commissioning groups across three of London’s most deprived boroughs are working together to overcome some of the area’s significant health and social care challenges

The Waltham Forest, East London and City (WELC) Integrated Care Programme has the opportunity to revolutionise care for a population of almost one million people in an area facing significant health and social challenges. The WELC care collaborative has brought together commissioners, providers and local authorities covering the area served by Barts Health NHS Trust. The geography covers the London Boroughs of Waltham Forest, Tower Hamlets and Newham and includes:


 - Clinical commissioning groups (CCGs) from the three boroughs.

 - Barts Health NHS Trust. 

 - North East London Foundation Trust.

 - East London Foundation Trust.

 - London Borough of Newham. 

 - London Borough of Waltham Forest.

 - London Borough of Tower Hamlets.

 - UCLPartners (UCLP).

The footprint of the UK’s largest trust, Barts Health NHS Trust, provides us with the unique ability to leverage the existing local examples of excellence in integrated care and deliver them at scale and pace across east London.

There is a real sense of energy and excitement among all partners in the WELC care collaborative providing momentum to make positive and lasting changes to people’s lives.

The boroughs of Newham, Tower Hamlets and Waltham Forest are some of the most deprived in London, with significant health needs and inequalities. There is also a rising need for care across the country as society gets older and we see more people with chronic illnesses. We know we need to personalise care so people stay healthy longer and, support them to live independently and reducing reliance on hospital services.

A snapshot of the health needs in WELC:


 - Deprivation is twice as high as the national average.


 - Half of the population belong to Black, Asian, and minority ethnic communities.


 - 30% of the population changes annually. The population is expected to grow twice as fast as the national average. 


 - The number of people over 65 is projected to increase by 7% by 2016.


 - Birth rates are 40% higher than the national average.


 - Hospital stays for alcohol and substance misuse are up to 50% higher than the national average.


 - Newham and Tower Hamlets have the second and third highest levels of emergency admissions for psychosis in London.


 - 22% of patients account for 80% of the hospital costs. 

Better outcomes

We know that people with mental health problems are more likely to attend A&E and be admitted to hospital and people with long-term conditions are more likely to have a mental health problem.As such, we have put achieving better outcomes and improving the experience for people with mental health problems at the heart of our vision for integrated care.

Local patients and carers have told us that it needs to be clearer who they should speak to and when, with a single point of contact and consistent information. They don’t want to have to repeatedly provide their details and they expect that we will share that information with others who need it to provide their care. They want all the professionals they come into contact with to act as a team.

Staff have told us that there are many things they could do differently with the right enablers in place, knowledge about who else is involved in the care of a 
person, and access to a joint care plan at the right time. 

The WELC Integrated Care Programme is our response to those needs. How we deliver integrated care in each of the boroughs is evolving but the programme partners have agreed a common set of principles: 


 - Systematic, regular risk stratification of the whole population to support case finding for those most at risk of hospitalisation.


 - Care that is centred on an individual’s needs to enable individuals to live independently and remain socially active. 


 - Care that is evidence-based and cost-effective.


 - Preventing admission to hospital wherever possible by supporting care at home or in the community.


 - Avoiding duplicated effort in situations where a patient has many people involved in their care.


 - Actively developing local providers and supporting collaboration in the way we contract.


 - Evaluating what we do as we do it and revising our approach as we learn about what we are achieving.


 - Learning from each other, learning from national and international integration programmes and sharing our learning outside the programme.

There are some exciting initiatives in place and all three boroughs already have demonstrated examples of multidisciplinary working. We believe that we can achieve impact at scale by combining these examples and rolling them out consistently across the three boroughs:


 - Waltham Forest GPs have been systematically risk stratifying the local population since 2010 and have been involved in regular multidisciplinary team meetings and care planning for high risk patients since 2011. 


 - Waltham Forest’s case management and rapid response programme has given more than 1,000 complex patients intensive care management and an individual care plan. 


 - Newham was part of the Whole System Demonstrator pilot and has an established assisted technology program as a result. 


 - A joint senior commissioning post between Newham CCG and London Borough of Newham has been established to manage and deliver the integrated care model.


 - Tower Hamlets GPs have been working together in small groups (networks) to deliver a range of care packages by sharing staff, skills and resources. The network incentivises the performance of the network by paying a proportion of income on outcomes.


 - The Tower Hamlets Dementia Partnership has developed a nationally recognised model for integrated care for people with dementia and their carer(s), with demonstrably improved performance and outcomes.

'System changes'

The model of integrated care for WELC is being planned based on what is already in place and working in partnership with people and their carer(s) in an attempt to ensure that services achieve the outcomes that are important to them. 

We have, in addition, adapted international best practice and evidence to WELC demographics to develop our model of care. The result is a suite of standard interventions that broadly cover supported discharge, care planning and coordination, and mental health liaison and Rapid Assessment, Interface and Discharge (RAID). These interventions will be supported by system changes like routine information sharing and primary care networks, and enablers like patient systematic engagement, clinical leadership and IT.

Partners have mapped their existing programmes and services against the collaborative vision and interventions to establish if there are any gaps. This exercise is being used to create three to five year operational plans with clear investment and savings targets.

The work is timely as both health and local government organisations need to make efficiencies. By joining up health and social care to provide more care in the community, we hope to reduce non-elective spend by 24-40% over the next five years. We believe the collaboration will also provide a strong platform for the Integration Transformation Fund announced in the 2015/16 Health Settlement. 

We have established programme management structures to ensure the WELC integrated care system meets people’s needs and is delivered successfully. The structure brings together local design, planning and delivery of the nine interventions.

There are three borough-based integrated care boards and a central programme management office (PMO). The borough-based boards are made up of commissioners and providers that are responsible for leading the local design and delivery of the interventions. The PMO leads on the ‘do once and share’ or ‘at scale’ workstreams of information and IT, contracting and reimbursement, and evaluation.

An executive group made up of senior managers from CCGs, local authorities and the PMO oversees the borough-based and PMO work and ensures commissioning approaches are aligned. An Integrated Care Management Board provides overall strategy and guidance for the program. 

The program reports to each borough’s Health and Wellbeing Board and each local authority reports through their normal governance structures. 

The WELC Integrated Care Programme is harnessing the energy and ambitions of all the patient and public engagement forums across the three boroughs. We are developing mature and equal relationships between the public and professionals and regenerating local communities through new approaches to service provision.

We have linked with Healthwatch to canvass the views of local people and are holding engagement events to get people’s input on how integrated care should be designed and its potential impact.

Patient and public involvement is embedded across the programme and will be an ongoing process. The programme will respond to feedback to ensure it maintains a focus on what matters most to the population. 

The whole WELC programme is underpinned by systematically and regularly profiling the whole population for their 12 month risk of admission to hospital with patients in the top three risk bands who are either over 65 or have one or more long-term condition as our target population.

Population risk profiles (using a standard score across all three boroughs) will allow the programme to continually reassess and validate the clinical case for change and more reliably map interventions and costs to patient groups.

The contracting model is being developed in a dedicated reimbursement working group. The group has agreed a road map towards an eventual capitation model in 2016/17 with an interim integrated ‘fee-for-service’ model in 2014/15. 

The interim model will promote integration of services by CCGs contracting with a ‘provider consortia’ for all the interventions. Bringing together provider consortiums to respond to an integrated care specification will pose significant challenges and will require specific provider organisational development.

A major challenge we are now working on is to understand the cost distribution across the whole health economy and we are engaging with expertise in the three local authorities to start to map this.

We are working with UCLP, our Academic Health Science Partnership, to develop our evaluation approach and methodology. Across UCLP, several boroughs have been implementing and testing different approaches to integrated care to deliver better quality care and improved patient experience, along with financial savings. This provides the opportunity for benchmarking and comparison with other teams, as well as a mechanism for broader learning and dissemination. 

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