Case Study 8: NHS West London CCG – Whole Systems Integrated Care

In a nutshell: Effective and efficient community services are the foundation of healthcare in the NHS. Shifting specialist care into community settings has been the focus of recent health policies in the UK to provide more flexible, accessible and timely care closer to people’s homes. The aim is to encourage people to live independently, and to give them greater choice and control over their health, as well as to reduce NHS costs and the increasing demand for hospital resources. NHS West London CCG are developing personalised, well-coordinated and seamless pathways of care across health, social care and the voluntary sector with the aim of delivering holistic care to support older people’s wellbeing, while shifting activity to community and primary care settings. Care will be delivered in hubs, in GP practices and in patients’ homes. The GP practices will use the eFI to risk stratify patients according to severity grade of frailty.

Whole Systems Care

NHS West London CCG is investing in a Whole Systems Model of Care to transform services for people aged over 65. The Model of Care has been co-designed via a system wide Steering Group with representation from local residents, patients and service users. The Whole Systems approach will be centred on the holistic needs of service users and their carers, involving them in all decisions whilst providing them with simpler access and a shared care plan. Care will be personalised and tailored to service users’ changing health as well as social needs, covering both planned and reactive needs, and empowering self-care. The model is delivered by integrated teams, consisting of GPs, Case Managers and Health and Social Care Assistants. These roles are designed as aspirational posts, which have a holistic – rather than purely clinical – focus.

The model will be delivered in GP practices and at local operational hubs, where joint teams work on a day to day basis coordinating the care and tracking outcomes; helping to coordinate the services as needed from different organisations, on behalf of the service users and their carers. Services can also be delivered in patients’ homes if they are unable to attend the practice or the hub. Co-location of teams at hubs allows clinicians to optimise their time with patients whilst ensuring patients receive multi-disciplinary team input; interfaces with community services, mental health, out-of-hours care, social care and the voluntary sector are key enablers.

Risk Stratification

Population based risk stratification will allow for a Whole Systems model of care based on individual needs of patients. The electronic Frailty Index within SystmOne alongside GP clinical decision making allows for risk stratification of the entire CCG cohort of people who are aged over 65. The level of care provided is defined by the tier the patient is in. Tiers 2 and 3 patients are offered a minimum of two extended care planning sessions per year with their GP and Case Manager. Tiers 0 and 1 patients are offered a minimum of one extended care planning appointment per year with a Health and Social Care Assistant. Patients are also supported to develop self-care plans, with tiers 2 and 3 patients having access to a ‘social prescription’ of third sector activities, which will enable to them to achieve agreed goals. Of course, the model is flexible, and will allow for reviews should a patient’s needs or circumstances change.  


Primary care is accountable for the care provided and takes a central role. There are 50 GP Practices across the CCG each with an average of 512 patients > 65 years old. The Whole Systems model is being implemented in 3 waves; preparation for wave 1 began in June 2015 with the hub launch in September 2015. Hub learning sets during the start-up are driving decisions about the clinical and operational processes to be used within the model i.e. risk stratification, MDT working and care planning. The learning from roll out in wave 1 will inform implementation in waves 2 and 3, which will be phased over the rest of 2015/16 and into 2016/17. Recruitment of the new Case Manager and Health and Social Care Assistant posts is happening on a rolling basis until posts are filled, as these new holistic roles are so critical to the model.

All organisations involved are working towards an aspirational Accountable Care Partnership commissioned to a single set of outcomes and enabled by shared systems and incentives. A ‘Heads of Agreement’ – a non-legally binding agreement – clarifies the objectives of the programme and is being signed by all partners. It articulates the conduct and behaviours required to successfully deliver the objectives; outlines a high level outcomes framework; includes detail regarding the governance of the service and wider engagement; and includes the Information Sharing Agreement as an appendix, which is fundamental to success of the programme

The overall aim of the programme:

Outcomes being used to measure impact:

An outcomes framework for Whole Systems across North West London has been developed and the outcomes are grouped into five key domains, which are detailed below.

1. People have a high quality of life

  •  Number of days in hospital. This will evolve into ‘Days at Home’ depending on availability of data.
  •  % of service users responding ‘very confident/fairly confident’ to the survey question: How confident are you that you can manage your own health?
  •  % of service users responding ‘yes’ to the survey question: Did you help put your written care plan together?
  •  Social care-related quality of life

 2. Care is safe, effective and people have a good experience

  •  % of service users responding ‘yes’ to the survey question: In the last 6 months, have you had enough support from local services, or organisations to help you manage your long term condition?
  •  % of service users with all of the following: care plan/goals set/crisis care guidance in previous 12 months
  •  A&E activity for ambulatory sensitive conditions

 3. Professionals experience an effective integrated environment

% of WSIC staff responding ‘strongly agree/agree’ to:
  •  Professionals who agree they are working in an integrated way to support service users and carers.
  •  Professionals able to deliver the patient care they aspire to.
  •  Professionals who would recommend their integrated care partnership as a place to work.

 4. Care is financially sustainable

  •  Spend within set capitated budgets for target population
  •  Shift in spend from acute to out of hospital

 5. Care delivery is efficient

  •  Emergency readmissions within 30 days of discharge from hospital
  •  Weekend discharge rate
  •  Non-elective admissions

In addition to this, West London specific outcomes are being developed to expand on the monitoring of patient experience, staff experience and the effectiveness of the model of care. Monitoring how long patients spend in each tier, as well as maximising the amount of time patients spend in the lower tiers, will be a key aim and this will be measured through use of the eFI.

For more information, please contact the Whole Systems Programme team at