HOW CAN WE ORGANISE AROUND PEOPLE AND THEIR NEEDS?
Dividing the population into groups of people with similar needs is an important first step to achieving better outcomes through integrated care. North West London partners aspire to care that is as personalised and responsive to each individual as possible. A one size fits all approach is inadequate and different sets of people have different needs. Grouping will help us create models that are based on similar, holistic, individually-focused needs, and will also help us think about the health- and social-care system in a more holistic way. The idea of grouping the population is to ensure that the model of care address the needs of individuals holistically, rather than being structured around different services and organisations. For example, someone who is mostly healthy would probably need quick, convenient and urgent access to routine care. Conversely, someone who is elderly and has multiple long-term conditions would probably need sustained continuity of care with longer primary care appointments and close coordination of services.
Most health- and social-care professionals already do this kind of grouping in an implicit way. They know which of their service users have similar problems and will require similar types of care and support. By making these groupings explicit, we will be able to come to a common and better understanding of the new models of care that are likely to be needed. The needs of the individuals are central to the programme and grouping the population will allow us to focus on sets of individuals with common needs. The groups will form the primary organising logic for new models of care, the outcomes we plan to achieve and by which we will measure our success, as well as new payment models to incentivise providers to achieve these outcomes.
Grouping the population does not mean that there will be resource redistribution between groups. Rather, it means that services that are already provided for groups will be provided in different ways, using different models that meet needs in a more holistic and individual-focused way.
Defining population groups will help meet our objectives for Whole Systems Integrated Care in three ways:
| 1. Grouping based on needs will enable us to put people at the centre of care | 2. Grouping will help us tailor services to specific needs | 3. Grouping will support local areas to take a phased approach to implementation of integrated care |
| We already group the population but these groups are centred on services or medical conditions (e.g, health and social, primary and secondary care, mental- and physical-health care). Grouping based on needs rather than organisational boundaries will allow new models of care that can respond holistically to the totality of people’s needs and personal needs. | International examples show that models of care differentiated by need have the greatest impact. However, it is not practical to have two million individual models of care across North West London. Grouping the population around similar sets of holistic needs is a practical way to tailor services to specific needs. | Grouping will enable the boroughs to tackle integrated care in a staged approach, rather than trying to tackle the whole population at once. Each local area can decide which group(s) they want to focus on first, according to local priorities and context. We will be able to prioritise areas of greatest need first, and then move on to the other groups. |