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Understand current care and future needs

The next step towards designing a new model of care is to understand the existing model. This section will lay out a series of steps to help providers understand the care that is currently being provided for the target population as well as the future needs of that population.


The first step in understanding what is happening currently is gaining an understanding of the target population group. This includes understanding the average spend, total spend, activity levels and variation in risk for the population in question. The exhibit below illustrates what this understanding might look like for the serious and enduring mental illness group. Providers should collaborate with commissioners in order to undertake this analysis, as they will already have collected some of this data as part of setting outcomes and informatics. For more information about informatics and data analysis, see Chapter 11: What informatics functionality will we need?

In addition to understanding these elements of the target population, it is also important to understand the other lenses that we have thought about mentioned in Chapter 4: What population groups do we want to include? In addition to service usage patterns, providers should consider a whole wealth of information at both individual and population level which can support design of more effective models of care. More detail about how providers might go about this is provided below but the lenses identified by the working group include:


Understand how frailty is distributed across the population and how it interacts with other long-term conditions. Frailty is increasingly being recognised as an important predictor of care needs and should be included as a vital lens for the elderly populations.

Levels of economic well-being

Deprivation scores include measures of economic inequality, access to care and environmental quality. These should be understood by providers as vital predictors of quality and accessibility of care.

Culture and individual behaviour

Different people with the same conditions will think very differently about the care they receive and will have different care needs as a result. Providers will need to understand the different behaviours of the individuals they care for to ensure that they are having the maximum possible impact.


Carers are vital to the health and well-being of many people with long-term conditions. Providers should understand the carer population in their area and collaborate actively with them to plan care and support.

Loneliness and social isolation

Loneliness and social engagement are vital to leading a happy and fulfilling life. Evidence suggests that improved social engagement and inclusion can also lead to better mental and physical health outcomes. There is significant potential for provider networks to invest in these areas to prevent appearance or escalation of need and therefore cost.

Utilisation risk

Providers across North West London are already using utilisation risk to understand their populations. They should continue these analyses to understand where the magnitude of risk is most concentrated in their population.

These can be understood in various ways, but will need both a qualitative and a quantitative approach to understand them fully. For the qualitative approach, providers will need to gather experiences from around the patch of service users and their carers and collate these into a set of stories that can be used to understand individual experiences. For the quantitative analysis, providers can use both publicly available and private data, including data available on deprivation from HSCIC (Health- and social-care Information Centre) or carer satisfaction from ASCOF (Adult Social-care Outcomes Framework), to understand the variation in experience of these lenses throughout the group. It is vital that providers and people who use services understand these lenses, as they are complementary to the population grouping itself. Providers can also reference the service user diaries that have been put together for North West London by Ipsos Mori, which can be found in Supporting Materials B: Care journeys that accompany this document. These provide examples of how a qualitative understanding of service user experience could be gained.


Part of detailing out a new model of care is deciding what workforce will provide which specific services. Providers will need to come together with the wider set of co-design partners in the working sessions to understand who is currently providing what services. The end result should be a care map of all the different people who provide services for the target population. This should include not only care professionals, but also volunteers, carers and the community, as they are vital, if unpaid, parts of the workforce. The exhibit below is an illustration of one way to think about doing this mapping.





Providers will need to understand how resources are currently being used in the system so that they can think about how to shift these resources to provide better care with the new model. The table below shows the allocation of costs for different groups in Hammersmith and Fulham. Each provider network will need to do their own analysis like this one to understand the current costs for their specific group, where the majority of the costs lie and which costs could be significantly affected. See Chapter 8: How can commissioners align provider incentives? for more detail.