Integrated Care: Its clinicians that make the difference

As clinicians we want to work in the health service to provide better care for our patients.  The only way we can do this is by being part of a team. The same is true for our social care colleagues. The relationships we have with other clinicians, managers and health and social care partners are absolutely vital if a community is going to meet the difficult financial challenges ahead and yet deliver the highest possible quality of care.

In Northamptonshire we formed our Integrated Care Partnership (NICP) in 2009.  We invited senior clinicians and front line workers from all major providers (including the LMC as the provider arm of primary care), as well as patients, carers, social care and the voluntary sector to come together with the aim of providing better integrated care to our mutual patients.  Our ambition was to use this partnership to break down and resolve all organisational barriers and interface issues.  We identified a series of quick wins that quickly established the value of the partnership, which still commands the attendance of all organisations 31 monthly meetings later!

We agreed a set of shared markers of success: decrease in emergency admissions and readmissions, decrease in length of stay, decrease in admissions to care homes, and ensure that we are able to honour the wishes of more patients in terms of their preferred place of death. Who could argue or put organisational barriers in the way of these markers?   We agreed that we would use the partnership to ensure that the right clinical leaders come together in the right meetings at the right time to make all of the important decisions.

We have already seen a 17% (440 patients) reduction in deaths in hospitals compared to last year following the introduction of new end of life service.  However, the most successful and ambitious scheme has been our £3 million Community Elderly Care Service. This all started when a Consultant Geriatrician asked me for 20 minutes on one of our agendas to present the concept. We quickly harnessed the collective enthusiasm around the table and ensured that doors of organisations on which we previously had to pound on heavily to find a solution were flung open due to the collaborative bottom up approach. The business case was quickly developed, piloted and approved. 

We are never going to agree on everything.  What we have developed over time are strong personal, as well as organisational, relationships that enable us to tackle differences of opinion in an open and constructive manner. For example, we continue to reconcile our ideological differences of the most appropriate place of care for patients by working our way through our Consultant to Consultant referral policy to agree exactly which patients should be seen where.  Because we have the right senior clinical leaders in place we can openly discuss and resolve all issues within the NICP.  We do not need to escalate to any higher authority, and in fact we would see this as a failure of our partnership.

Once we agree a collective course of action, each clinical leader takes this back to their organisations and ensures the appropriate changes are made. Where change is not delivered and there are further obstacles to be overcome we bring this back to the partnership and work together to resolve them.  The hearts and minds battle is so much more easily won when clinicians are leading and driving the change.  

Clinical Commissioning: a Management Trainee perspective

As a management trainee, joining the NHS and going straight into clinical commissioning organisation was an exciting prospect, being at the heart of the changes. But after a four week induction into the NHS with the numerous wishes of ‘good luck’ that derived from what was seen as the complexity of clinical commissioning, perceived views of tensions between clinicians and managers, and beliefs that clinical commissioning would be no different to GP fundholding, made the prospect more daunting.

When I started at Nene Commissioning however it was clear that the group of most active GPs were passionate about clinical commissioning and think that they really could deliver something new, to improve patient experience and clinical quality. The clinician manager divide that I had come to be wary of, due to recurrent warnings, is not apparent. For the most part GPs appear grateful for the support network that Nene Commissioning is providing for them, and see how this can facilitate them to make changes, in areas that they believe will really benefit their patients and enable clinical commissioning to become much more than a ‘talking shop’.

From what I have seen within the short space of time that I have been in Nene Commissioning, I believe that if clinical commissioning organisations can enhance and facilitate the passion, experience and knowledge of the most engaged GPs and managers it will show its ability to truly deliver for patients.

My First Week at Nene

Tom Dodd – Senior Locality Manager – East Northants – Nene Commissioning
Having spent the previous year working quite closely with 31 PCTs across London, I witnessed an assortment of ways in which commissioning organisations were organised to be involved and committed to improving the wellbeing of people on their patch. With a background in mental health, I’m passionate about how people are supported to influence the services that they use, and in this respect I feel that an organisation’s behaviour is a much better mark of their values than what’s declared in their ‘statements of intent.’

So, on joining the team here at Nene, I was struck by an authentic sense of working together and a feeling that what we bring through our experience and beliefs is respected. Good start.

I’m pleased that I took some time to find out about how Nene had progressed, and how it had behaved as an organisation to get to this point.  This was reassuring - despite the challenges ahead (or maybe because of them) Nene looks steadfast in involving people who can hold the group to account, and with whom we can talk openly and listen to. It’s inevitable that Nene will grow and mature; this cooperative culture feels strong enough to endure as a solid underpinning for the group. Even better.

I’m looking forward to getting to know people across the locality. I live here too, and I want my family to have access to the best that’s available. It’s no longer only managers who are making the commissioning decisions that will impact on my family, it’s also some very skilled clinicians who I know already (in the first week!) are assertive and vocal in making their case. Best of all.

I think that clinical commissioning will also evolve and reveal a set of values that will resonate with most people. For now, the overriding sense of collaboration and open dialogue is the most welcome feature on joining Nene.

This will definitely affect your authorisation...

I have a question for colleagues working in CCGs – how many times do you hear the phrase ‘this will affect your authorisation’?  Once a month? Once a week? More?  I think at present I hear this at least once a day.  So far this week the things that I have to do or else my authorisation will be affected are:  reconfigure 5 acute hospitals across the patch; ensure every GP practice in the county carries out Health Checks; lead the equality and diversity strategy for the county; land on the moon. I am dreading next week’s requirements!!

The issue seems to be one of control.  CCGs have in many places been given control, through the delegation of budgets.  Staff not working in CCGs feel the responsibility to deliver whatever their agenda is, but come up against people like me in CCGs who may have different ideas on what or how things should be done.  They need to find a way of influencing me, and at present it appears to be beating me with the ‘this will affect your authorisation’ stick!

As CCGs we have a tendency to protect our independence.  At the same time we do have new responsibilities and we do have to rise to them.  We can’t pick and choose the responsibilities we want, but have to take on the whole range.  We do however have the freedom to decide how we do things and how we prioritise things.  Both of these may be (and are likely to be) different to what has gone before.  A key challenge for us as CCGs is how we build confidence in those who are delegating responsibility to us that the way we want to work will be successful.  The more we do this, the less others will feel the need to try and control us.  So maybe I will take it as a marker of my success when I start to be told what will affect my authorisation slightly less often.

10 Top Tips for Successful Case Management

Guest Blogger - Lesley James.  Lesley held various nursing roles before she joined NHS Management and was recently appointed one of Nene Commissioning's new Senior Locality Managers.

One in three of us have a long term condition; that’s around 15 million people in England.  Patients with long term conditions use seven out of every ten inpatient bed days and over half of GP appointments.  Supporting these patients effectively and thus reducing the impact they have on local health and social services has been a key driver for our work in Northamptonshire.  For the last three years we have been running a case management model, Pro Active Care (or PAC).  Through PAC we have significantly reduced the emergency admission growth rate in patients with long term conditions (0.7% admission growth rate in those practices undertaking PAC, compared to 4.5% growth rate in our comparator PCT sites).

PAC now involves more than 55 of our 70 GP practices and covers a population of over 600,000 people,

Our clinicians work closely with their patients and their carers to create innovative services that better support people at home. So what are our ten top tips for making case management a success?

1)      Involve all the practice and community services teams in case management – LTC management should be a contractual arrangement.

2)      Identify those patients who are at greatest risk of emergency admissions and readmission, using a range of information, such as risk stratification tools, frequent A&E attendance data, practice intelligence, out of hours’ attendance and ambulance frequent caller data.

3)      Set up weekly practice meetings involving community nurses, GPs and other members of the primary care team to case discuss, develop pre-emptive care plans, and provide timely interventions. These will include increased community nursing support, medication reviews and social care involvement.

4)      Include patients who are at the end of life in case management. We have found that over 60% of patients in PAC who are dying are able to do so in places of their preference, by and large at home. This is particularly important for those patients who do not have malignant disease, and who are more likely to be admitted into hospital at the end of their life.

5)      Work with acute service colleagues to identify patients suitable for PAC and make sure they are able to directly refer the patient into PAC via the practice teams

6)      Work with social care colleagues so that they too can directly refer the patient into PAC

7)      Enlist support from the third sector so that patients can have social needs met, this will include carers organisations so that the needs of carers are not forgotten.

8)      Make sure that there are good interfaces with all services that support patients with LTC’s. This will include Integrated Care teams, Mental Health teams and specialist services, such as diabetes heart failure, and Palliative Care services.

9)      Develop a reporting system for practices and community services to account for their activity associated with case management

10)   Provide monthly feedback to practice and community teams on the progress made in reducing their emergency admission rates.

LTC management is not a quick fix, something that is done once and then forgotten, but is an ongoing responsibility for all involved. It is everyone’s business and requires a whole system approach, which means that organisational barriers must be dismantled so that professionals are able to maximise their commitment to work collectively to improve health outcomes and quality of life for their patients.

The difference between a PCT and a Clinical Commissioning Group – a GP Chair Perspective

Guest Blog by Darin Seiger

Darin Seiger is Clinical Chair and Accountable Officer of Nene Commissioning.  He has been GP Chair of Nene Commissioning since it was established in 2007.

I still remember the shock and disappointment I felt during the lecture in my 2^nd year of medical school when we had the session on “How the health service is actually run” – how the hell had the model evolved where managers make all of the important decisions including whether to even involve clinicians at the coal face? Madness!

Well here we are as clinicians, after years of saying we want more power and influence, ready to seize this opportunity and take these responsibilities on.  But individual clinical leaders who have grasped this vision need the support of all their local clinicians.  We have to rise to this challenge and win the hearts and minds of our generalist and specialist colleagues to work with us as a team. To do this we have to show that we mean business and that we will make a difference and not end up repeating the previous cycle of promising change and delivering the best part of bugger all.

Two years ago I called up the Medical Directors of our main provider units (two Acute, one Mental Health, one Community provider and the LMC Chair - as the provider arm of primary care) and suggested the six of us, with our combined 128 years of working in Northamptonshire, needed to start working together to provide the leadership to drive collaboration across our organisations.  We have built the crucial relationships between us, and now, through our Northamptonshire Integrated Care Partnership (NICP), we are working together to drive clinically led change though our health and social care system. 

As clinicians we can now stop asking for permission to make changes to improve the care for our patients and just get on and do it.  Implementation of our clinical ideas (‘product’) is king, and without our managerial colleagues to turn our vision into reality, we would not have the capabilities to deliver ‘product’.  We are very lucky in Nene – we have a dedicated management team that passionately believes that clinicians should make the important decisions and effectively we are committed equal partners in our determination to make change happen.

The exciting part is that as clinicians, we can break through barriers that no managerially-led system could ever do, in terms of shaping and delivering better clinical care.  We don’t need the nth degree of evidence and bureaucracy to make a decision to commission a new pathway or service because as clinicians we know they changes will deliver higher quality of care and return on our investment.  Where historically it has taken months for business cases for new services to be agreed, as clinicians we will not tolerate these delays in the system.  Ultimately we know that delays in services starting are delays suffered by our patients.

Put simply the differences between a PCT and CCG are:

·         Collaborative bottom up approaches to solving issues and designing better care for our patients whose pain and frustration we feel when things do not go right

·         Understanding that clinicians need to understand and be consulted on what the issues and potential solutions could be – it simply raises clinicians’ antibodies to be told “this is the problem and this is the solution”

·         Local leaders, with long and deeply embedded roots in our practices and communities, see ultimate success as what is achieved locally, and do not view these leadership  positions as transitional until the next opportunity comes along

7 Reasons Why GPs Will Make Great Commissioners

‘The most brilliant idea, with no execution, is worth $20.  The most brilliant idea takes great execution to be worth $20,000,000’.  Derek Sivers, President, CD Baby

 I often find myself drawn to the books of entrepreneurs (check out Derek Sivers book - Anything You Want), and a consistent theme is that ideas are easy, but execution of ideas is what really counts.  Putting GPs in charge of commissioning is, in my view, a brilliant idea.  On its own it’s worth $20.  Many people believe that this idea is not possible to execute.  But, if we can, it will mean far more than any amount of money to those patients whose lives it could touch.

So what is so great about the idea of putting GPs in charge of commissioning?  Why might clinical commissioning groups be different and far more effective than PCTs? Understanding this is important, because it is the first step to making it a reality.  There are at least seven areas where GPs can make a big difference:

1.       GPs can use their experience of what their patients need to ensure that money is spent on those areas that will deliver the greatest benefit to patients

2.       GPs can use their experience and the experiences of their patients to identify where duplication, errors and all forms of waste occur in the system, and use commissioning as a lever to drive this out

3.       GPs leading commissioning can work with clinical colleagues in hospitals and community care and put clinical care as a priority over individual organisational interests

4.       GPs can form a real partnership with their patients to give patients a much more effective voice in the design and delivery of care

5.       GPs can commission pathways of care that integrate services around the needs of patients, rather than contract with organisations who are then left to deliver care in isolation without any join up between them

6.       GPs will drive the need for high quality information to underpin all aspects of commissioning, an area that has historically been very weak.  Better quality information will make for better quality decisions, with better quality outcomes for patients.

7.       GPs will use evidence to drive the commissioning decisions they make.  The use of evidence was historically left to Public Health departments, but in CCGs it will drive decision making across the organisation.

But overall I think there is too much talk about whether GP commissioning is a good idea or not.  What there is not enough focus on is the detail of how we are going to turn this idea into something that creates real value for the populations we serve.