Galvanising local care systems

Amanda Sullivan, SRO of the Mid-Nottinghamshire Better Together vanguard, tells NHE’s Josh Mines about their work to create an innovative integrated care system in the area.

Vanguards in 50 areas across England have been leading the way towards new, innovative models of care since the pilot areas were selected back in 2015. These bodies, set up to bring together partners from across health, social care, local government and the third sector, are now showing real signs of change, making tangible progress on improving care for patients and easing pressure on time-short service providers.

One system which has shown particularly positive signs is Mid-Nottinghamshire Better Together. Serving 320,000 people across a mixture of large towns and rural areas, the vanguard faced a challenge when it was first chosen to be a pilot area. But as we speak, it appears that the SRO responsible for the vanguard, Amanda Sullivan, is positive of the progress that has already been made.

“People now spend less time in institutional care than they would have done,” she told me as she outlined how the vanguard has benefitted patients.

“We’ve reduced our hospital bed days by 13%. Long-term admissions to residential and nursing care have reduced as well. We are also able to intervene more proactively before people get too dependent and lose their confidence to function in a home or out-of-hospital setting.

“This has come from a mixture of people feeling more supported, but also if they have to go to hospital, coming out quicker and not having to go into care homes – or reducing the need for people to go in the first place.”

Communication is key

The changes which Sullivan spearheaded, however, were not overly complicated. She told me that the first step was all about bringing service commissioners and providers together, and using feedback from local service users to tackle the fragmented and complicated nature of the original system.

“We couldn’t work out why different parts of the system didn’t communicate,” Sullivan explained. “A big part of the work was therefore to talk to local systems and clinical and care professionals about what the right model of care would look like and how we could improve things.

“The first building blocks were to get teams working in an integrated way across health and social care based around GP lists,” she continued. “We had seven of those teams across the area, and what they do is implement some software that allows the general practices to risk-stratify their population to see who is more likely to need more intervention, including patients who are vulnerable – such as those who have been in hospital recently.

“That was quite different to how they’d worked before because although they knew who was coming out of the surgery, they didn’t have a complete picture about people who were starting to become more vulnerable.”

Better signposting services

Another innovation that the vanguard has pushed forward, and that is central to improving many other local systems, is signposting patients better at the front door of hospitals. “We had a single front door at our emergency department that created single streaming and pointed people to the right place,” the SRO explained.

“We also have an urgent care centre which had the same principle, where we put out-of-hours GPs with the hospital team and co-located them as well. That helped us streamline when people do present at the hospital for emergency care.”

But for this kind of system to work, Sullivan stated that a clinical navigation tool was necessary to give staff the confidence to send patients in the right direction: “When we were doing the design, the professionals said it’s all very well wanting people in the right part of the system, but it’s very complex and we don’t know what all the services are.

“So we’ve put a clinical navigation service in so that the emergency department, the ambulance crews and the GPs can ring one number, and they know the nurses within that service will go to the relevant people and organise a rapid response within two hours so they don’t need to go into hospital.”

Of course, the benefits to this new system have not just been for patients, but for staff and organisations working together to provide care. “We have found that where we’ve had to put additional investment, like community teams and care navigators, we’ve had a return on investment of 123% overall across the programme,” said Sullivan.

“And from a professional point of view, staff who work in those teams say it’s a much better way of working as they feel more supported because they know they have people around them.”

Challenges ahead

It’s not all been plain sailing, however. Sullivan pointed out that when it came to the challenges that have cropped up on the journey towards integrated care, it was not always easy getting staff to work well under a new system.

“One of the big obstacles has been that people are very used to working in their own organisations, in their jobs,” she said. “That was a big thing, as that stopped people working in different ways because they don’t know or have the confidence to do something differently.

“A lot of places where they have done a single front door at the emergency department took two years to work effectively because the emergency department teams and primary care services have very different ways of operating, thinking about clinical risk, and different protocols and requirements from the CQC.

“But nobody wants to not feel like they are not following the governance, and it took a lot of time to develop the protocols for streaming for patients deciding what’s best for them.”

So what was Sullivan’s secret for engaging staff and getting them fully behind the radical new plans? “We talked about what we were trying to achieve in quite general terms, and then we worked with specific groups of professionals who were experts in areas like the single front-door working and out-of-hours teams – and did it in such a way that they really influenced what the care models would look like based on their own experiences,” she explained.

Generalisations are always difficult when it comes to systems like the 50 vanguards, which operate over considerably different areas, with different needs and different demands. But if there was a message to take from Nottinghamshire’s successes, it’s that this way of working is the key to driving up care quality under very difficult circumstances.

“One of the really positive things is that where we’ve successfully brought teams together and they had to work differently, it’s built its own momentum and breathed its own success, so it complements how teams work and causes people to come up with their own ideas,” she continued. “It goes to show that if you galvanise all bits of the system you can make a significant difference. There have been some things which haven’t worked so well, but that’s part of the learning.”

Though it seems that considerable challenges remain, we wrap up our conversation on a positive message that many other people leading care systems across England will be encouraged by: “I firmly believe that from a patient and financial point of view, an integrated way of working is the right thing to do,” Sullivan stated.

Though pressures on the NHS show no sign of easing, with innovative thinking, collaborative working and old-fashioned elbow grease, local leaders are still confident that they can deliver a care system the country can be proud of.

Top image: Jason Batterham




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