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Purpose, Population and Place: 12 Practical considerations in designing and building a integrated model of care


Cathryn Sloan ,

AQuA (Advancing Quality Alliance), GB
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Julie Want,

AQuA (Advancing Quality Alliance), GB
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Helen Kilgannon

AQuA (Advancing Quality Alliance), GB
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Introduction: The publication of the ‘Five Year Forward View’ by NHS England in 2014 described how “the traditional divide between primary care, community services, and hospitals…is increasingly a barrier to the personalised and co-ordinated health services patients need”.  It outlined how boundaries can be dissolved by creating new models of care; based around partnerships, integration and moving away from separate funding streams for different parts of the health and care system.

Further publications, along with the NHS England New Care Models programme have continued to develop thinking, particularly with regard to the development of Integrated Care Systems (ICS) (population 300,000-2.7million) and Integrated Care Partnerships (ICP)(population ~300,000).

Description of practice change: Over the last seven years AQuA has worked closely with a number of system leadership teams across several localities in the North West of England, supporting them with the design and implementation of place based care.  Latterly, we have supported a number of emerging ICP Boards as they come together to collaboratively transform services and ultimately, population health outcomes.

Aim & theory of change: AQuA has synthesised their experience of working with systems over the last seven years to describe 12 practical steps that system leadership teams can use to develop and implement models of integrated health and care.  These are:

Have a clear purpose and vision for change

Deeply understand the needs of the population

Ensure population and people are represented

Make the system visible to itself

Support the system leaders

Develop a clear and purposeful plan

Understand the system resource

Develop clear and robust governance

Assemble a team of technical experts

Appoint a programme director

Build on existing foundations of integrated locality or neighbourhood teams

Implement a proof of concept

Targeted population & stakeholders: AQuA supports stakeholders from across the system, including acute, community and mental health providers, commissioners, Local Authority (including Public Health and Adult Social Care), voluntary, community and faith sectors as well as patients and citizens, to design, develop and implement integrated models of care.

Timeline: As the number of ICS’s increases (currently 14 across England), the need for leaders to collaboratively lead for place not organisation becomes more important.  NHS England has described an ambition for all systems to develop into ICS’s over time. This would suggest that there is a continued need for practical advice and support for system leaders working in place based systems of care.

Highlights: Implementing place based models of care is complex, difficult and takes time.

AQuA’s 12 practical considerations in designing and implementing place based care gives system leaders realistic and useful steps to provide direction and support.

How to Cite: Sloan C, Want J, Kilgannon H. Purpose, Population and Place: 12 Practical considerations in designing and building a integrated model of care. International Journal of Integrated Care. 2019;19(4):554. DOI:
Published on 08 Aug 2019.


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