Using whole population data to put integrated care into practice: the North West London experience

Introduction: Integrating health and care provision is a high priority for  the UK National Health Service, emphasised in the recently published NHS Long Term Plan.  However, health and social care is delivered by independent systems, with significant differences in culture and ways of working.  Consequently service users and carers are often left frustrated by repetitive assessments, ineffective hand-offs between different teams, duplicative efforts which waste resource, and a lack of coordination.

Practice Change: In North West London an innovative digital platform has been developed to foster closer working between different providers. The Whole System Integrated Care (WSIC) dashboards link provider data from four acute, two mental health and two community Trusts across North West London, 380 GP practices and social care data from eight boroughs to generate one of the largest integrated care records in the country. It can be reviewed by the range of health and social care professionals involved in a patient’s treatment, thereby providing a joined-up care history.

Aim: We seek to demonstrate the applications of this innovative digital platform and discuss some of the lessons learned in its development.

Population and Stakeholders: Co-design, co-production and co-evaluation is at the core of the WSIC process. Over 30 organisations, community groups, lay partners, and  importantly  service users and carers came together to develop a shared vision for integrated care: to enhance quality of care for individuals, carers and families; maximize independent living; and support individuals to lead full lives as active participants in their community.

Highlights: We will use the application of the dashboard in Harrow, a Borough in north-west London to demonstrate its benefits. Here the WSIC dashboard supported segmenting the 240,000 residents by frailty and acuity. Having aggregated data across sectors and health and care providers - by individual, GP surgery, and locality - the dashboard was invaluable in informing the starting point and formation of integrated care models in Harrow.  Traditionally such data would sit in native systems and the totality of health and care needs would consequently remain out of sight.

Sustainability and Transferability: The tool continues to develop and evolve in response to clinical and service user feedback through a Clinical Advisory Group. By handing ownership of the tool to its beneficiaries, the product is adapting to the needs of the service users in North West London and this flexibility ensures it can continue to evolve as population needs change.

Conclusions: The WSIC dashboard enables case finding and managed care of individuals through providing visibility across all care settings, thus allowing care to be targeted where it is most needed. Patient activity is viewed across care coordination teams, practices and community nursing teams to enable earlier intervention and ensure resources are better managed.

Lessons Learned: We will demonstrate the benefits of the dashboard and draw out lessons learned using a Q&A style panel discussion exploring broad themes from a public policy and practical provider perspective.