Delivering Integrated Care

Roundtable:
The ‘What’ and the ‘How’

Date: Thursday 12th September 2019
Venue: Warrington Village Hotel

On Thursday 12^th September, Practicus ran a roundtable for CEOs, Accountable Officers and Programme Directors in the North West focused on the challenges of delivering sustainable integrated care. The event was well attended and led by Sir David Dalton, who gave a short presentation of his own experience ahead of chairing the discussion.

INTRODUCTION

Sir David has been an NHS Chief Executive for 25 years and is well known for his time serving at Salford Royal – a CQC ‘outstanding’ Trust and an accredited Global Digital Exemplar. He was involved in the creation of the Northern Care Alliance (NCA) and became its first leader. Hospitals within the NCA, particularly Salford Royal and Rochdale Infirmary, are recognised as having some of the most developed integrated care systems in the country.

Though recently retired, Sir David still invests his considerable passion and energy into the NHS he loves. Not long ago, he was involved in developing new Local Care Organisations – comprising integrated care services across 5 localities. These are ambitious undertakings, hoping to achieve the triple goal of improved health outcomes, better user experience and low cost.

A VIEW FROM SALFORD AND ROCHDALE

Sir David began with a quick overview of the successes at Salford and Rochdale and how more integrated care systems were progressively introduced.

Since 2015/16 new models of care have been presented with the following impact:

• 7% reduction in emergency admissions compared with a 4% increase nationally.
• New urgent care multi-disciplinary team responds to referrals within 2 hours and manage a person for 72 hours at home. In 2018/19 over 3,000 patients benefitted, and ambulance conveyance reduced by 10.1%
• The enhanced care team focuses on high-risk elderly patients with frailty. Using a common shared digital record to ensure all information relating to the person is available at all times, there has been a 12% reduction in falls-related admissions (3,289 to 2,898).
• New integrated discharge team, including a housing officer, provide a ‘trusted assessor’ system enabling patient assessment by any member of the team, regardless of district of residence. Delayed transfers of care (DTOC) have been reduced by 75%; so that Salford now in top 2% DTOC rate in the country and a 15% reduction in the rate of permanent admissions into care homes. 
• Rochdale’s ‘home in a day’ scheme reduces length of stay from 3.2 days to 2.3 days and 70% of patients discharged in the same day.
• The cost of the introduction of new models of care = £8.4m gross, which enabled a reduction to the net cost of service by 1.4% to 5.8% reduction to costs (variable to project)

David addressed the room:

“You will know the objectives that you are wanting to pursue in your systems and the issues that your wanting to give attention to. I am going to ask you to consider the extent to which you are very clear on your design objectives. Perhaps you are just taking the requirements of the long-term plan rather than working with your partners and communities to create something which suits your own local place-based needs? Do you find a template approach helpful or do you as leaders in health and care systems prefer to find your own solutions”

The main design objectives mentioned included:

• Neighbourhood teams
• Improving access to GP and community services
• Improving Care Pathways
• Services that can help at home or in the community
• Sharing information between health and social care professionals
• Self-Care: Maximising Independence

RESPONSE FROM THE ROOM

DESIGN OBJECTIVES

• “I think the NHS is very good at coming up with an objective, a target to aim for. However, what it’s not good at is planning ‘how’ it’s actually going to get there, because in a lot of instances it doesn’t know where it is starting from. It wants to get to an integrated care organisation, but it doesn’t really know how fragmented or how broken its starting point is. Therefore, it doesn’t know how big the change needs to be or how it’s going to do it.”

• “I agree. The 5-year view and the long-term plan is a great vision but this is not actually a ‘plan’ as such, because you need to know ‘where’ you are starting from in order to get to the end.”

• “So we have got GPs who are challenging our own thinking and our own employees and we have public health embedded in the trust. So it is a long journey and this kind of thing takes a long time and that’s the reality check of it all, because bandwidth is not there. Therefore, to answer your question David, it’s really hard.”

• “I thought it was really interesting when you said ‘a long term plan gives us what we need to do, not the how’, and I don’t really have too many problems with that, per say, because I actually think we needed the long term plan to kind of reset the whole system and that’s what it does. By doing this it actually says we are going to take a population health approach and we are going to really put the people at the centre of that and we are actually going to redesign the system to actually achieve that. But that’s the bit that’s difficult and those people who like structure and process would like a design template that says, ‘here you go that’s what you need to do it.”

• “I think it has to be much less structured than that, I agree there needs to be ‘some’ structure, but you need to get the balance between the two. We need to be somewhere in the middle and I think it is that bit about giving some structure but actually allowing the population – based around the care communities – to actually start to shape that up. So, you could say, this is what it might look like, how does that feel for you and really engage people in a completely different way as we move forward.”

• “I think one of the issues that we have had for so many years is that the ‘top down’ template. ‘One size fits all’ approach doesn’t work. Things have gone up in the air with the primary care networks, but I think that it all comes back to the question, is it a ‘what’ or a why?”

• “I think sometimes we get the question wrong and then we try and template it and say, ‘this is how everybody has to do it’. It doesn’t allow you quite that wriggle room that you need to make it work, and that’s just some of my frustrations over the years in the NHS.”  

• “The NHS stands for National Health System not the National Hospital System and that is where the problem starts. This is because ministers see the big estates where all the ‘sexy’ stuff gets done as the important thing and that’s what gets headlines, not any particular government mind. Every government for the last n years sees hospitals as the most important bit of the system but the incentive is to get activity into hospitals and that’s why we have got to have this debate at a national level.”

• “While I was trying to do a little bit of learning about the NHS, I had never realised that the NHS was not supposed to be a national system in the way it is now. Apparently, prior to that it was supposed to be a much more regional localised system, and I think that would have worked a lot better.”

• “What’s the approach of we are all in this together to try and make improvements rather than let’s just keep bashing people over the head to make the change now? Let’s get the system together to see how the system can respond and lets all try to make improvements that we are trying to do.”

• “I remember when it went from PCTs to CCGs, no one was arguing about the form, because that was kind of set. Whereas, what it feels like is that it’s a bit of a free-for-all at the moment and that everybody’s vying for power and there isn’t enough workforce. The penny has not quite dropped and actually what we all have to do is work on how we shift pension expectations.”

• “I wonder whether it’s less about being templated and more about timeliness. I think there are lots of things we can do if we are given the time to do it, but we are so constrained by our annual planning cycles and our budgets and everything else that really starts to drive us.”

• “Our communities and our system know what we need to do but because the time scales are so tight actually you are feeding that beast as well as trying to make some significant changes in the system as you are working. In the system I work in there is one ICS and there are five ICPs so we are in the same ICP. I have seen significant shifts in behaviours from all of the partners around the table and it feels so much more connected, collegiate, moving forward in the same direction.”

• “I’m not wanting a template because the localism is where we will get the innovation which is required. I do not need the same things. That’s where I think primary care can lead because they are the main people who have seen every bit of the patient and the public journey. Everything goes through general practices and they know what is needed for their local population of 30 to 50 thousand better than any of us and if we ignore that we won’t get an integrated care system.”

GOVERNANCE AND LEADERSHIP CHALLENGES

“Can you identify what you are finding is starting to work? What might work in one locality might not work in another, so is there anything you are doing differently which is gaining traction and impact?”

• “I think there are tensions between quite hierarchical statutory organisations who have a very structured leadership and where primary care coming into the partnership, they have a very flat structure and leadership. We have leaders who sit in CCGs they are not necessarily the same leaders who sit out in primary care and I think there is a big challenge around how we develop leadership within primary care and bring them to the table in a bit of an equal way to enable them to partake in the conversations that are developing across the ICP.”

• “I think it’s important that we all acknowledge that a high performing team that looks like a unit for moving forward requires trust and you can’t pressure cook that. So, we have to acknowledge that takes time. If the vying for power to not be dominant, then trust has to be in its place, and I don’t think I’m seeing that culture change in the systems that I’m working in.”

David interjected, “I think the summary is that we recognise we need a framework, but we need also to be able to determine what is needed locally. How are you getting organisations to commit collectively to change?”

• “I think it depends on where you are in the system. So from our ICP perspective, although we haven’t had to make big decisions yet, we have made some decisions and we have done it collectively around the table and we have a shadow ICP board. We meet with the leadership every single week, which is about building relationships and about building trust.”

• “We are looking at an ICS perspective and we are looking at the hospital agreements. It’s absolutely where we think we need to go because we do have a situation where we can agree a variety of things around the table and then when you look around suddenly that decision has gone, and we no longer are going to implement. I think that’s created a level of frustration amongst acute providers, particularly because we see that we have rotas that need to be filled, services that need to move etc. We are having those conversations now and actually starting to think a little differently about the chairing arrangements of our ICS, our provider board and our joint collaborating commissioning group to think about whether there should be a single chair. So that where those decisions are being made in each part of the system, actually there is no wriggle room.”

• “Locally you mentioned place. I think place has been quite important, because we have built the system around places and that in itself has bought people together. Although I hear what you are saying in terms of having gateways and processes to go through but actually this is about hearts and minds. This is about cultural differences between organisations and getting people focused on something that they all share and care about, which is place.”

•  “If health and care services are moving to place-based decision making, you may be heard by politicians but how do you get heard by the people and who are going to be allocating the resources to allow those things to happen? With respect, whilst it’s important to lobby nationally with politicians, in order to have your voice in the place you have got to be able to connect with it.”

MONEY AND THE COST FOR CHANGE

“Are we managing the cost of change by making sure organisations are using services in a cost-effective way? Are there still lessons we can learn?”

• “Well I wouldn’t say we are doing it well. We are not awash with cash. I think we have got a better understanding now, so there are some things we are working on, without ICP, where we know if we do something it creates a huge saving for us but creates a big cost impact on the CCG. In terms of, ‘Is there enough money in the system to allow you to do transformation at scale and pace?’ The answer is just ‘no’, we are really struggling with that.”

• “The lack of awareness of resources is duplicated. When we looked at the 1,800 people who receive home care in one of our hospitals, over 35% also had a district nurse going into the home and 48% of them had an unpaid carer and there were also people coming in from 3^rd sector organisations. Evidently, that was a surprise to the organisations where there was that level of duplication. The homecare recipients were telling us ’please can we have fewer people coming in as it’s getting in our way’. Therefore, not only is duplication a waste of resource, it makes the care less effective. We need to put a plan in place to reduce this active duplication of services.”

• “I think the health system is skilled at swallowing money and simply just spending it. We have had £450 million pounds worth of transformation funding in Greater Manchester. It’s not enough, it’s not been for long enough and it’s not always been invested in the best possible way. That’s usually because it’s not been done as a system and we almost got the money too soon, because you need to bring the system together before you receive it.”

• “I know you said something earlier about we might not know where we are spending, but do we know where we are getting value? I think we have lots of debate about where we are spending but that bit about where we are adding value, I don’t think we understand that as well as we should.”

• “We have to be mindful that given the demographic of the population, someone who is 65 has 8 times the average health care cost of someone who is 35. People are living longer, So the demographics have an impact on whatever we do.”

TENSIONS WITHIN INTEGRATED CARE SYSTEMS

“Are you experiencing tensions and power and decision-making responsibility shifts within Integrated Care Systems?”

• “Well it’s very early days for primary care networks, isn’t it? And you’ve got GPs in a position that they will need to grow into and that in itself is a challenge. In terms of how they were created, it very much supports the model.”

• “One thing I say to all my staff when sat within an ICP is don’t put great expectations on one partner. Put great expectation on ‘us’, use that language. What I hear is ‘primary care network will handle that’ even though we’ve already taken on 16 items from the list. Who’s going to break that news to the GPs? It’s evident we over expect. So, let’s admit we want clinical leadership at the heart of what we do and recognise they are a fixed asset in the community. However, it’s not all about GPs, it’s about the community nurses, the voluntary sector too. Let’s give them the time to work out their own relationships. I do think patience is a virtue and the ‘us’ language is well learned and well-articulated. That’s just a message I would give to everyone around primary care networks.”

• Yes, you’ve got to have all your partners developing your vision and developing what you’re trying to achieve.”

• “Ultimately, we need more partners to support primary care. So much depends on primary care and the place, neighbourhood, MDT being ‘successful’. But what we actually need are the big providers with the infrastructure and support to come to us at primary care and ask, ‘What is it you need?’”

• “My observation over the last three years, is that NHS organisations are getting better at collaboration but they spend too much time going through that initial phase of ‘we must all be involved and collaborate.’ We need a group of people to physically do it from our existing network of organisations and then understand how are we going to give them the permission to start to make some changes? It comes back to ‘who are the leaders?’ ‘who will start to change the dynamics of power?’ If we think ahead it’s going to be interesting how primary care networks are going to all be at the table but going to be performing in a way to really start to make an actual difference.”

• “If you take our ICS, probably 80% of the activity and relationships and partnerships and change will take place inside the ICPs. Probably a huge chunk of that will take place in each separate ICP. I think the ICS role is about broaching those things that go across the whole system, that don’t just impact on the ICP but that impacts across a wider range. So looking at tertiary services, looking at some of those things that you have just mentioned, and I think that’s where the value will come in.”

• “I think where we are at the moment is that ICS are maturing at a very different rate. I don’t that we have the relationship right between the regulators and the ICSs. I don’t think quite everybody knows what’s been handed over and how it’s going to work.”

• “Going back to general practice and PCNs, it’s a really tough gig. CCGs were meant to sort out all our problems, but they haven’t. It’s giving people responsibilities on top of a really heavy day job and a really complex set of patients. You have to give them bandwidth, you’ve got to invest in that. One of the things we picked up in our experience working with GPs is we need lots of support and development and unless we do that, we are not going to be successful.”

• “I think there is a risk with CCG mergers that they merge to do the same thing as they do now. Actually, there should be a merge to do something different and that’s where the focus needs to be. I think that is a real challenge for the CCGs to actually change organisational form but also change what they are trying to do.”

ORGANISATIONAL DEVELOPMENT ISSUES

“What are we doing about investing in our people, particularly those who are inside the organisation, rather than at the top of it? What are your views about the OD issues associated with this major transformation change?”

• “I think that you can put a blanket OD process in place but maybe another way to do it is to do something like the ‘Nuffield trust partnership assessment tool’. So you can take an individual partnership through that process and learn your strengths and weaknesses and then put an OD program around that.”

• “I think one of the things that always surprises me about the NHS is how little people move around from one organisation to another. They may move from one key hospital to another key hospital, but you don’t tend to get them moving between types of provider or moving in and out of commissioning and I think that’s a big gap in the NHS organisation.”

• “I have worked in both health and social care interestingly but the number of people who have crossed the divide between the two and have an understanding of both I found to be very low in terms of numbers. And also, recognising the value of needing to understand both sides and then of course working in the third sector and other parts so you get a true understanding of what it means to work on a place-based footprint.”

• “I honestly, don’t think the people around this table are the best ones to determine what is best for their locality because the issue that you are trying to change has to be understood by the people who are dealing with the impediments of making improvement. How do you make that happen? How do you organise in a place, borough, county the way in which staff can come forward from different areas, and get them to blend their ideas because they are coming from different organisations and then support them in taking change forward?”

CONCLUSION

David finished the discussion with ways staff at Salford were helping integration across different sectors.

• Work together as a single, high performance team: ‘one system, one budget’ 
• Commitment to place-based Systems of Care – focus on neighbourhood and not organisation
• Co-operate and engender a culture of “Best for Service” 
• Collective responsibility – share the risks and rewards – no fault/no blame
• Working together on a transparent basis: collaborate and co-operate to identify solutions, eliminate duplication of effort and mitigate waste
• Communicate openly about major concerns, issues or opportunities 
• Learn and achieve full potential by sharing appropriate information, experience and knowledge
• Adopt a positive outlook by behaving in a respectful and proactive manner 
• Act in good faith to support achievement of desired outcomes
• Create best value – cost will not be shifted between organisations 

Thank you to everyone that attended this roundtable discussion. If you would like more details, including an anonymised transcript, please contact jon.webster@practicus.com. 

About Practicus

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