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How do local areas decide which groups to focus on?

There are three factors which will need consideration when choosing a group: potential financial opportunity, potential impact on individual outcomes and implementation readiness. These are detailed below.


As part of the Whole Systems Integrated Care programme we have done extensive analytics on the total costs and average per capita cost of care across health- and social-care. Please see Supporting Material E: Review of Analyses During Co-design Phase for further detail.

1. Potential financial opportunity

Evidence also suggests that integrated care will reduce waste in the system and shift care closer to home, which will help reduce reliance on avoidable costly admissions to acute hospital- and residential-care settings. The extent to which financial resource gains can be achieved varies across the groups, and depends on local factors such as the current total costs and the current proportion of costs that go to avoidable acute care.

2. Potential impact on outcomes

Evidence suggests that integrated care will help facilitate seamless coordination between health and social services across organisations, which will help focus services on the holistic needs of individuals. Further explanation of how integrated interventions can do this is provided in the chapter on models of care. This approach has the potential to greatly improve outcomes for certain groups. The degree to which outcomes could be improved will vary across the groups and across the different boroughs of North West London. It depends, for example, on factors such as current outcomes achieved versus national averages and current utilisation of different types of services.

3. Implementation readiness

The final piece of choosing a population group is how ready local systems are to implement integrated care. This is the most locally specific, and heavily depends on the context within each locality. The two key factors to consider here are provider readiness, which includes the level of excitement and commitment to the programme and availability of pooled budgets.

These variables are very locally dependent and it is something that needs to be worked up in detail while building the outline whole systems plan. See Chapter 12: Next Steps for more detail.


  • Which group is your organisation best suited to caring for?
  • Which group could benefit the most from more integrated care?


To implement the Whole Systems approach you will need to plan for and complete the following:

  • Review detailed analyses and information on population grouping to deepen understanding of approach.
  • Organise discussions between commissioners, providers and lay partners in a locality and decide whether to adopt North West London population group or another approach.
  • Gather data at an individual level to be able to replicate analyses for your local area (more information is provided in Chapter 11: What informatics functionality will we need?).
  • Conduct analyses of local population to understand characteristics of chosen population groups, including their current outcomes and spend.
  • Agree with partners the criteria for prioritising which population groups are the focus to begin changing models of care for.
  • Decide which population group(s) will be used to organise business plan