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Foundations for ChangeFoundation Healthcare Group end of programme report

Dartford and Gravesham NHS TrustGuy’s and St Thomas’ NHS Foundation Trust

March 2018

About this report

This report tells the story of the Foundation Healthcare Group; from the impetus behind the collaboration and vision, through to how it has worked in practice and the lessons learned.

As part of this, the Vanguard Voice pieces throughout the report offer insight into the impact of the programme, from a range of different perspectives including patients, clinicians and other members of staff.

Foreword

It’s becoming increasingly clear that closer collaboration between NHS providers has to be central to the future NHS landscape. That means closer relationships between hospital and community-based care. It also means hospitals working in new, and more integrated models. It’s these approaches that we’ve been seeking to support through the New Care Models programme over the last three years.

Of course, simply merging hospitals won’t always be the right answer. We have a litany of inglorious examples of this kind. That’s why the collaboration between Guy’s and St Thomas’ and Dartford and Gravesham is so compelling.

It promises a clinically-led model that realises the benefits of partnership and scale, but avoids costs and distraction that can come with big transactions. If we can get it right, it may be a model that can be replicated in other parts of the country. This could be particularly the case where smaller or more remote hospitals are struggling to sustain services on their own.

The early signs at Foundation Healthcare Group are promising. Patients are being seen closer to home. Changes to care pathways are ironing out different approaches. And there’s some suggestion that recruiting staff to the new group model has become easier.

If these trends continue, then we’ll be able to say with some confidence that the Foundation Healthcare Group – and what it evolves to become – is a bellwether for the wider NHS.

Jacob West National Lead, New Care Models programme

3Foundations for change: The Foundation Healthcare Group end of programme report

Summary

The Foundation Healthcare Group (FHG) is a partnership between Guy’s and St Thomas’ NHS Foundation Trust (Guy’s and St Thomas’) and Dartford and Gravesham NHS Trust (Dartford and Gravesham).

As one of 13 acute care collaborations within NHS England’s New Care Models programme, the FHG has sought to develop a sustainable model of care that makes best use of scarce resources and could be replicated across the NHS. It has sought to achieve the benefits of collaboration without the changes to management control necessary for mergers or acquisitions.

What happened?

The FHG was accepted onto the New Care Models programme in September 2015, a joint memorandum of understanding was signed in April 2016, and financial resource followed in June 2016. This was the beginning of almost two years of focused collaborative working to further the aims of the programme, which formally concludes in March 2018.

During the programme, the FHG focused on seven workstreams to best address the opportunities and needs of both partners:

• three clinical (cardiology, paediatrics and vascular care), and

• four non-clinical (IT, location, Dartford Health Partnerships and designing a new governance approach to collaborative group working)

These areas had flexibility as to how they approached collaboration within the framework of the model. The clinical workstreams started in June 2016. They have all reported early signs of benefits for both patients and staff.

Over the duration of the New Care Models programme the work of FHG has delivered improvements to both organisations involved. Key highlights include:

• over 37,000 patient travel miles saved between November 2016 and December 2017

• 853 appointments held locally at Dartford and Gravesham rather than Guy’s and St Thomas’ in the same period, enabling care to be delivered closer to home for the patient

• £800,000 of procurement savings generated for Dartford and Gravesham in the first year of Guy’s and St Thomas’ delivering its procurement function.

What next?

The Vanguard programme finishes at the end of March 2018. As a result of innovations made within the clinical workstreams, several initiatives are now being adopted as business as usual within their specialties. In the case of the Proactive Care for Older People Undergoing Surgery (POPS) programme, these innovations are being expanded to other clinical areas.

Furthermore, Guy’s and St Thomas’ and Dartford and Gravesham are keen to continue to develop their partnership into a new form of sustainable group model – the Guy’s and St Thomas’ Healthcare Alliance – from April 2018 onwards. With Dartford and Gravesham as a founding member, the Guy’s and St Thomas’ Healthcare Alliance plans to expand to include new members, who will also benefit from the advantages of a ‘group’ approach and the learning developed as part of the Vanguard programme.


Context

Given their geographic proximity, collaboration between Guy’s and St Thomas’ and Dartford and Gravesham did not start with the publication of the NHS Five Year Forward View in October 2014; many clinical and strategic relationships predate this. However, the funding and impetus behind the successful bid to become one of the New Care Models programme’s Acute Care Collaboration (ACC) Vanguards enabled the formation of the FHG and a deeper level of partnership.

Dartford and Gravesham NHS Trust

Dartford and Gravesham provides a full range of local hospital services for people living in North Kent and Bexley, south east London. The trust works with partners to provide a range of specialist services locally and offers a number of regional services including kidney care. It employs around 3,000 staff, and has an annual turnover of £215m.

The trust faces opportunities such as how to capitalise on a range of new housing developments, including the development of Ebbsfleet Garden City. Ebbsfleet will include a Health and Innovation Quarter (HEiQ), which is aiming to be a local, regional and international hub for health care delivery, integrated multi-professional health education and innovation. The population of those within a 45-minute drive of the city will be approximately 4 million. This increase in population will have a significant impact on Dartford and Gravesham as the key NHS trust in the area.

Challenges to providing consistently high quality healthcare include how to attract the clinical workforce – particularly specialists – needed to treat patients locally and provide reliable access to excellent healthcare. The constraining financial environment and being a whole-site Private Finance Initiative (PFI) makes it difficult to achieve the benefits of scale to allow Dartford and Gravesham to save money or make significant investments independently.

Dartford and Gravesham saw collaboration with another provider as being important to help them continue to deliver sustainable, local healthcare services. Many organisations choose to follow a merger or acquisition approach, which can prove expensive and distracting, while others choose to stay as a single organisation, which poses its own financial challenges. Dartford and Gravesham chose to explore a third option of working with Guy’s and St Thomas’ in a more structured partnership, using international examples of hospital groups as inspiration.

Guy’s and St Thomas’ NHS Foundation Trust

Guy’s and St Thomas’ is an integrated healthcare organisation providing a full range of local hospital and community services for people living in the boroughs of Lambeth and Southwark. The trust also provides specialist care for patients across south east England, including cancer and cardiothoracic services. The Evelina Children’s Hospital provides general and specialist services for children from London, south east England and further afield. The trust employs around 15,000 staff, and has an annual turnover of £1.4bn.

Guy’s and St Thomas’ saw a partnership with another provider as helping them meet their five-year strategic plan to develop as a system leader. Developed in 2014, the plan confirmed the trust’s mission to provide world-class clinical care, education and research that improves the health of the local community and wider populations that the trust serves. Guy’s and St Thomas’ aims to build on its track record of being part of numerous local, regional and national clinical networks that support the provision of co-ordinated patient pathways.

The Foundation Healthcare Group

Dartford and Gravesham are one of Guy’s and St Thomas’ key referring hospitals. As such, the two organisations have a history of working together that predates the Vanguard programme. In addition, for a year prior to the Vanguard programme, the


leadership teams from both trusts came together to discuss how best to develop the partnership. The initial idea was simply to explore how the two organisations could become stronger by working together, in terms of quality of care provided and financial sustainability.

The executive teams first met to discuss an application in June 2015. These first conversations focused less on specific clinical opportunities but instead on the extent to which there were shared values between the two organisations. Both teams were encouraged by these discussions and the level of alignment in terms of organisational values.

In addition, these conversations highlighted strong alignment in terms of the importance of clinical leadership, and the need to have a partnership of co-leadership and equal representation to accelerate collaboration. This last point was especially important given the asymmetrical nature of the two trusts.

“It was clear from the beginning that Guy’s and St Thomas’ and Dartford and Gravesham had similar organisational values, and similar views on how to approach issues. Collaboration between organisations is never easy, but being on the same page for many areas is a good place to start”

(Sir Ron Kerr, Chief Executive of Guy’s and St Thomas’ at the time of commencing the Vanguard programme and continued Senior Responsible Officer for the Vanguard programme.)

It was at this stage that the collaboration determined it would not seek to follow a merger or acquisition approach, but rather look to base the partnership on mutual commitment to work together in a ‘third way’.

The resulting partnership, named the ‘Foundation Healthcare Group’ for the New Care Models programme, aimed to develop a sustainable local hospital model that makes best use of scarce resource and could be replicated across the NHS. It aimed to improve outcomes and access, improve cost effectiveness and meet the challenge of increased demand.

Following application in September 2015, the FHG was successful a month later in becoming one of the 13 Acute Care Collaboration Vanguards.1 A formal memorandum of understanding was signed between the two trusts in April 2016.

Figure 1 summarises the key milestones of the programme.

Since formation, the FHG has focused on seven workstreams: three clinical and four non-clinical:

Figure 2: The seven FHG workstreams

Vascular: To develop new models of care and support access to specialist opinion

Paediatrics: To develop new models of care in epilepsy, streamline flow through the hospital for paediatrics and standardise pathways

Cardiology: To reduce unwarranted variation, streamline pathways from primary to tertiary care and deliver more care locally

Information Technology: To digitally link Guy’s and St Thomas’ and Dartford and Gravesham

Location: To explore agile working

Dartford Health Partnerships: To streamline service delivery contract management

Governance: to develop a new governance model to formalise the collaboration

The three clinical workstreams have sought to improve clinical pathways which cross both organisations, thereby improving outcomes and reducing duplication. While there were already good clinical relationships between parts of the two trusts, the explicit commitment of the organisations to work together was designed to further existing, and help create new, relationships.

1 For a summary of the lessons learned so far from these vanguards, please see ‘No hospital is an island: learning from the Acute Care Collaboration vanguards’ (NHS England, 2018) https://www.england.nhs.uk/wp-content/uploads/2018/01/acute-care-collaboration-learning.pdf

https://www.england.nhs.uk/wp-content/uploads/2018/01/acute-care-collaboration-learning.pdf

https://www.england.nhs.uk/wp-content/uploads/2018/01/acute-care-collaboration-learning.pdf


Figure 1: FHG key milestones

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Vanguard voicesVanguard Voice – Where it all began

Sir Ron Kerr - Guy’s and St Thomas’ NHS Foundation Trust

Chief Executive of Guy’s and St Thomas’ at the time of commencing the Vanguard programme and continued Senior Responsible Officer for the Vanguard programme.

Dartford and Gravesham are one of Guy’s and St Thomas’ key referring hospitals and, as such, have a history of working together that predates the Vanguard programme. This experience gave us confidence that the Vanguard programme could help develop ideas for further collaboration, and provide learning that would be useful to a broader community.

As part of the development of our corporate strategy, we sought to build closer relationships with hospitals actively referring into Guy’s and St Thomas’ – in part driven by the acknowledgement that we could be better at building those relationships, but also on the basis that considering the needs of a broader network of patients would result in benefits for patients being referred through the system, and mutual benefit for the organisations involved.

While collaboration between organisations is never easy, we felt that both organisations were underpinned by a set of shared principles. In the course of exploring the options for creating a formal arrangement, we established that not only were Guy’s and St Thomas’ and Dartford and Gravesham’s organisational values aligned, but we also shared similar views on how to approach issues.

In the course of pre-Vanguard programme discussions it became clear that the real issues for Dartford and Gravesham were the financial and clinical sustainability of a relatively small trust in the face of an ever-changing NHS environment. From Guy’s and St Thomas’ point of view, our sustainability relied on a successful network of referring hospitals as this was crucial to be able to cope with the local workload. The shared work became not just about how to improve patient flow, share ideas and build relationships, it also became about how to achieve those things in a way that would enhance the sustainability of Dartford and Gravesham.

The introduction of the Vanguard programme provided the two trusts with an opportunity to reflect on whether our work to date on collaboration was relevant to the wider system. We realised that, given the current healthcare context, creating a sustainable local hospital within a system was something that would result in valuable learning more widely. The resulting Vanguard application was a joint bid between ourselves and Dartford and Gravesham, with NHS England particularly interested to view the collaboration from Dartford and Gravesham’s perspective.

Developing a partnership within the framework of the Vanguard programme allowed us to explore collaboration as a way to enable individual organisational ambitions as well as shared ones. Dartford and Gravesham understandably valued their autonomy as an organisation and were in a much better position to relate to their local community than Guy’s and St Thomas’ could. In addition, at Guy’s and St Thomas’ we weren’t convinced by the notion that the only way to help the system was simply by acquiring hospitals; our size meant that we needed to consider how best to internally organise an increasingly large organisation in order to be effective and efficient going forward. We concluded that the answer was not to acquire hospitals, but rather explore and build different types of relationships with other organisations.


Impact

The Foundation Healthcare Group programme has sought to improve:

• patient experience

• clinical outcomes

• resource sustainability.

As the programme has developed, a range of further benefits have been realised as a consequence of the relationships built between the organisations.

Improved patient experience

Care closer to home

The FHG has sought to find new ways to make care more convenient for patients to access.

For example, the programme has supported the creation of a multidisciplinary diabetes foot clinic at Dartford and Gravesham for patients who present with vascular complaints caused by diabetes. Prior to the clinic, patient journeys could be convoluted, with multiple appointments or admissions at Dartford and Gravesham prior to treatment at Guy’s and St Thomas’. The new clinic enables the team to make immediate decisions with patients, resulting in fewer outpatient appointments, and faster access to urgent treatment at Guy’s and St Thomas’ where required. The clinic was established in August 2017, holding 90 outpatient appointments between August 2017 and January 2018.2 Initially held monthly, the clinics became weekly as a result of patient need. Funding has been acquired through the NHS England Diabetes Transformation Fund to continue the weekly clinics over two years.

In addition, through the paediatrics workstream, a multidisciplinary neurology service has been established at Dartford and Gravesham. Using resources from the Vanguard programme, a paediatrician consultant with a special interest in neurology was recruited to the Dartford and

2 Figure does not include the number of visits made to patients on the ward by the MDT team

Gravesham team in September 2016. In turn, this led to the recruitment of the first Roald Dahl’s Marvellous Charity3 funded epilepsy nurse specialist in Kent. Dartford and Gravesham involved children and their parents in the appointment process. By avoiding the need to travel to Guy’s and St Thomas’, this service alone has saved over 17,000 patient travel miles between November 2016 and December 2017 through. In addition, the number of new or follow-up neurology outpatient appointments taking place at Dartford and Gravesham almost doubled between 2016-17 and 2017-18.

Reducing waiting times

Through closer working together, the FHG has sought to find ways to reduce duplication and enable patients to access services faster.

The cardiology clinical workstream saw duplication in how patients were being referred for tests when diagnosed as suffering from blackouts or faints caused by a sudden drop in the supply of blood to the brain (medically termed syncope). There were a large number of duplicate appointments, and high rates of patients not attending multiple tests.

A new cardiac syncope clinic was established at Dartford and Gravesham’s Darent Valley Hospital in June 2017 to see patients who would otherwise have been admitted to hospital from A&E. Instead, these patients were able to go home the same day and return to the outpatient clinic within a week, avoiding unnecessary inpatient stays. GPs began referring into the service in October 2017. Over a four-week period 100% of patients were happy with the short waiting time for their appointment, and 95% of patients felt they received enough information about their condition during the clinic.

3 Roald Dahl’s Marvellous Children’s Charity helps to make life better for seriously ill children in the UK: www.roalddahl.com/charity


Extending the Local Care Record, used across King’s Health Partners,4 to Dartford and Gravesham has also enabled clinicians to see patient records across the organisations and further reduced the number of duplicated diagnostics.

Improved support for frail patients

The FHG has enabled services which have been shown to be effective at one of the trusts to be shared and implemented elsewhere.

One such example is how elderly and frail patients are cared for before undergoing surgery. The Proactive Care of Older Patients Undergoing Surgery (POPS) service has been running at Guy’s and St Thomas’ since 2003, with two research studies showing that it reduces the amount of time patients need to stay in hospital, and the rates of complications after operations.

There was a clear case to transfer the service from Guy’s and St Thomas’ to Dartford and Gravesham. The Vanguard programme provided the resources to do so. The transfer was led by two registrars who split their time between the two trusts – enabling them to develop the service at Dartford and Gravesham with the support and expertise of the larger established centre at Guy’s and St Thomas’. In addition, a Darzi Fellow was recruited in 2017 to evaluate the translation of the service from Guy’s and St Thomas’ to Dartford and Gravesham.

Following open recruitment, the registrars have subsequently been appointed to the consultant-level post leading the POPS service at Dartford and Gravesham on a job-share basis. Their appointment exemplifies how acute care collaboration can enhance professional development opportunities and support recruitment and retention.

The implementation of POPS at Dartford and Gravesham has been a success, with the service expanding beyond vascular surgery to general surgery. It is now funded on an ongoing basis through the surgical directorate.

4 Founded in 2009, King’s Health Partners (KHP) is the Academic Health Science Centre collaboration between Guy’s and St Thomas’ NHS Foundation Trust; King’s College Hospital NHS Foundation Trust; King’s College London and South London and Maudsley NHS Foundation Trust

Clinical outcomes

Reduction in unwarranted variation in outcomes

Through the clinical workstreams, the Vanguard programme enabled clinicians to better understand how patient pathways differed across the two trusts, and to find opportunities to standardise where appropriate.

For example, within the cardiology workstream, 20 patient journeys were mapped to identify duplication and opportunities for standardisation. As a result, seven disease-based pathways have been streamlined to reduce variation for patients.

Within the paediatrics workstream, 10 standardised pathways were implemented in A&E, with junior doctors and lead nurses assigned to review data and monitor results. In addition, 11 guidelines through primary care were developed, using external input from clinical commissioning groups.

Easier to access specialist advice

The FHG clinical workstreams have sought to find new ways to rapidly share specialist advice between organisations.

For example, clinicians now have remote access to the network of the other trust so that patient information can more easily be shared. The implementation of remote access has resulted in the reduction of duplicate appointments being booked and has offered immediate access to medical records.

Successfully implementing ‘Skype for Business’ at Dartford and Gravesham has also enabled clinical teams to work more closely together, providing a practical solution for easy collaboration between sites. For example, within the cardiology workstream consultant-to-consultant Skype clinics began in April 2017. Cardiologists at Dartford and Gravesham are more quickly able to access tertiary care for specialist advice, making care closer to home a reality for patients as they have access to specialist input without having to travel to Guy’s and St Thomas’.


Vanguard voicesVanguard Voice – Parent perspective

Kirsty Theobald – mother of a Specialist Neurology Network patient

Kirsty describes the experience of her son Ben in the new service

My experience here at Darent Valley Hospital has been fantastic. We first came here three years ago and quite quickly my son Ben was transferred to the Evelina London because his seizures needed a second opinion – he has myoclonic seizures so they are very unusual. His care was then shared between the two hospitals, so we come back to the hospital around every six months.

However, more recently we met Emily, the Epilepsy Specialist Nurse, who has been absolutely amazing. Since she started here the level of care has been fantastic, and because she is based at Darent Valley Hospital I now have someone locally to phone if I have any worries or problems. We can phone her anytime Monday to Friday and she’ll get back to us.

There are now support groups to get involved in which is fantastic, and this sort of thing wasn’t available before. In fact, when Ben was first diagnosed it was quite scary because we didn’t really have anyone to ring. Everybody did their best, but there wasn’t the level of support available there is now, and this is why I think this unit is growing and getting bigger.

Resource sustainability

Redesigned workforce

The Vanguard programme has provided a framework by which teams can explore new and creative roles within clinical teams. This will help build a sustainable workforce at the trusts. For example, the cardiology workstream at Dartford and Gravesham has used community pharmacists by creating pharmacist-led hypertension clinics and creating opportunities for cardiac physiologists to deliver scans in Dartford.

Shared knowledge and expertise

The FHG programme has sought to foster joint working between non-clinical staff in functions such as finance and procurement. Staff have reported that the programme has enabled a line of communication and access between the two organisations that would not have been possible otherwise. Over the duration of the programme, Guy’s and St Thomas’ and Dartford and Gravesham have shared knowledge regarding commercial contracts, clinical coding, private patient services and much more.

“This way of working is starting to become really embedded in way Dartford and Gravesham thinks, acts and behaves”

(Gerard Sammon, Interim CEO Dartford and Gravesham.)

For example, Guy’s and St Thomas’ now delivers the procurement function for Dartford and Gravesham. This has realised the immediate benefit of saving Dartford and Gravesham £800,000 in its first year and provided Dartford and Gravesham greater leverage in terms of buying power. This procurement partnership has already been expanded to other organisations.

In addition, as part of the Dartford Health Partnership workstream, it was agreed that the opportunity to develop a more robust, standard approach to Service Level Agreement (SLA) management at Dartford and Gravesham would be explored. It was understood that this learning could then be shared with Guy’s and St Thomas’ and potential future members.


A standard approach has now been developed to enable effective management and monitoring of SLAs between partner organisations. This focuses on the whole agreement life-cycle process from pre-contract considerations through to service design, setting service levels, performance criteria, ongoing reporting, review and risk management. There is a clear plan to complete the required development and move to testing the system by March 2018.

Wider benefits

Beyond the explicitly designed benefits of the FHG, a number of additional outcomes were generated through the improved relationships created by the programme:

• Collaboration for mutual benefit. Guy’s and St Thomas’ have focused on relationship-based, collaborative governance models to avoid the risks associated with traditional merger and acquisition models. This learning can be shared with NHS organisations more widely. The Ebbsfleet Garden City signifies opportunities and challenges for Dartford and Gravesham. One challenge is the increasing demand for services. The Health, Education and Innovation Quarter (HEiQ) at Ebbsfleet offers access to a regional diagnostics centre, expanding the diagnostic potential to screen, treat and research care improvements in the locality. In addition, learning from the East Midlands Radiology (EMRAD) Consortium Vanguard, Dartford and Gravesham are considering how to work differently with radiology when they move to the same Information Technology (IT) platform as Guy’s and St Thomas’.

• Shared learning. Dartford and Gravesham have robust performance management systems in place for referral to treatment (RTT) and cancer waiting times, which Guy’s and St Thomas’ are seeking to learn from. Guy’s and St Thomas’ have shared their expertise regarding commercial services and contractual processes with Dartford and Gravesham. Dartford and Gravesham and Guy’s and St Thomas’ are both developing strategic

outpatient transformation programmes. Learning from these processes will be shared between the trusts, with other Guy’s and St Thomas’ Healthcare Alliance members and with members of the Association of Health and Care Provider Groups (see Box 1)

• Reach of the programme. The FHG has supported the development of relationships within the wider health geography, encouraging greater collaboration across regions including across Sustainability and Transformation Partnership (STP) footprints. Clinical staff have applied to work at Dartford and Gravesham because of its partnership working with Guy’s and St Thomas’. Recent consultant recruitment feedback has shown that Dartford and Gravesham’s association with Guy’s and St Thomas’ meant that they applied for, and were successful in being appointed to, a consultant post they would not normally have considered.

• Organisational Insight. The FHG has highlighted additional aspects of IT that needed to be updated and which may not have been noticed without the Vanguard programme. At an organisational level, participation has provided Guy’s and St Thomas’ and Dartford and Gravesham with insight into the challenges the other faces, and greater insight into the wider health economy.

Box 1: The Association of Health and Care Provider Groups

The Association of Health and Care Provider Groups is a learning network across the four Vanguard Acute Care Collaboration Group Trusts and the three Essex Success Regime Trusts. Members are: Guy’s and St Thomas’ NHS FT; MSB Group (Mid-Essex Hospital Services NHS Trust, Southend University Hospital NHS FT and Basildon and Thurrock University Hospitals NHS FT); Northern Care Alliance (Salford Royal NHS FT and Pennine Acute Hospitals NHS Trust); Northumbria Healthcare NHS FT; Royal Free London


Vanguard voicesVanguard Voice – Clinical leadership

Ruth de Las Casas – Darzi Fellow

Ruth is on the clinical leadership development programme sponsored by Lord Darzi and is an Anaesthetic Registrar

I am a Darzi Fellow working within the Proactive Care of Older Patients Undergoing Surgery (POPS) team. POPS is a perioperative service, looking to give best care to the older and more frail surgical patients. It’s a service that was established at Guy’s and St Thomas’ 14 years ago and has grown to be a large and well-known service throughout the hospital. As a result of both its clinical and research work it is increasingly looked to nationally and internationally as a leading model, and it is widely admired within the field of perioperative medicine.

A number of people have been employed specifically to run the Vanguard programme, but my role - in evaluating this new service - is an end point, and a measure of success, of the Vanguard’s work.

My role requires working between the two Trusts. Setting up POPS as an offshoot of an established service has ensured there is a hub of knowledge, advice, and support, who are easily accessible and who have an interest in making our service work.

However, you can’t just ‘copy and paste’ the service in. The different structures, systems, staff and patients at each site all play a huge part in shaping their service. It’s been a real eye-opener seeing what the challenges are, and what the facilitators are. I think everyone makes judgements about new services - some will assume something is great because it’s coming from a big London Hospital, others will assume it’s terrible because it’s coming from that same big London Hospital.

I’ve had lots of conversations with different staff who’ve been involved in helping us get POPS set up at DVH – Health Care Assistants, nurses, allied health professionals, and doctors – and they all agree POPS makes good clinical sense. POPS is such a fantastic service, it’s the care that you’d what your grandma to have – so being a part of spreading that has been really positive.

Gathering patient feedback will be a part of our evaluation, and I’m really looking forward to hearing experiences and working to improve them. But in a way the best feedback will be that they’re not really aware of us as a separate entity – hopefully we’ll blend seamlessly in with the rest of their excellent care!

Being a part of a Vanguard, a project that is the direct result of a government initiative, has given me a new interest in what’s going on in the wider world. I went into medicine for the medicine, and as a trainee doctor there’s more than enough to keep you interested just learning how to best do your job.

As a junior doctor I have always felt very distant from policy – local, let alone national. Being a part of the Vanguard programme has given me a direct view of where some money is going, and how good initiatives can make a difference to the health service.

In the future, I’d like to see POPS spreading nationally - improving patient care in trusts of all different shapes and sizes. I hope we’re able to take the work that we’re doing now and crystallise it into something that will help other be able do it themselves. For me personally, I hope the learning I gain this year will help me establish a brilliant perioperative service for older patients wherever I end up working as a Consultant!


Lessons learned

The FHG programme has sought to capture the learning from developing a healthcare provider group. This will benefit the continued partnership between the two trusts and offer learning for the NHS as a whole.

What worked well

Clinical workstreams

Rapid acceleration of projects and a tighter focus on areas for improvement within cardiology, vascular and paediatric services have resulted from the Vanguard programme. The structure and rigour provided through a formal programme and additional project management support enabled the workstreams to make changes at pace. The high level of commitment and equal nature of the joint clinical leadership was also crucial.

Programme approach

Dartford and Gravesham and Guy’s and St Thomas’ spent a significant amount of time prior to the start of the Vanguard programme understanding each other’s key drivers and challenges, and considering how to make best use of scarce resources and workforce. This provided clarity between organisations, and the subsequent aims and objectives of the programme remained consistent throughout its delivery.

The FHG’s decision to ‘go where the energy is’ when selecting clinical workstreams enabled teams to make progress quickly and positively. This decision aligned with a non-traditional merger and acquisition approach. Those involved in the FHG fostered a supportive tone to the relationship between the organisations, empowering a creative environment and encouraging discussions. In addition, both Guy’s and St Thomas’ and Dartford and Gravesham were aligned in trying to achieve something greater than traditional financial flows might typically support.

Key learning

Scoping and objective-setting

Time set aside for a scoping phase with both trusts helped avoid the ‘firework’ effect (starting off with a bang before fizzling). This was also true at a clinical workstream level.

Setting clear objectives for clinical workstreams was also deemed crucial for success. This empowered decision making. Linked to the importance of objective-setting was the concept of being comfortable with ‘failing fast’. Workstreams could make rapid decisions about whether a current course of action was going to deliver an objective or not, and adapt accordingly.

Information technology

IT was critical for joining up clinical delivery across organisations. Making changes within the IT workstream was challenging because of the different IT systems employed by the two trusts, and because of the complex nature of organisational change. Changes to IT were implemented around other significant trust IT priorities. As a result, the IT workstream did not have the focus and urgency that other elements of the programme had.

Workforce

The fixed-term nature of the programme and uncertainty about funding made staff turnover a challenge and continuity in roles would have helped with momentum. The FHG discovered recruiting the right people with the right skills to key roles was critical. The programme initially recruited a project management skillset. Due to the nature of the challenges being faced, the programme needed steer from people with a more operational skillset. This provided knowledge of how to run a service so that it could move forward into business as usual as the programme progressed, and enabled work to progress across a complex system.


Vanguard voicesVanguard Voice – The future

Sir Ron Kerr – Guy’s and St Thomas’ NHS Foundation Trust

Chief Executive of Guy’s and St Thomas’ at the time of commencing the Vanguard programme and continued Senior Responsible Officer for the Vanguard programme.

As work in the Vanguard programme gained momentum, the approach generated some real successes in terms of building relationships; and really good work in clinical areas, patient experience, efficiency and productivity. We began to consider how our partnership with Dartford and Gravesham could be replicated in other settings, and we began to think more about a wider network of organisations. As such, the Vanguard story has evolved from an ambition to build good relationships between a hospital and one of its key referrers to something much larger.

With the formal close of the Vanguard programme, the work will continue in the form of the Guy’s and St Thomas’ Healthcare Alliance – this is a group led by Guy’s and St Thomas’ with Dartford and Gravesham as a founding member. It has the potential to deliver a high-quality NHS service, deliverable because efficiencies are built into the service and because it can consider how workforce challenges can be addressed in a much more transformational, collaborative way, and think about how to overcome challenges in individual organisations by looking over a wider base.

Our experience through the Vanguard programme has undoubtedly helped us reach the position we are now in. It has taught us that in order for a partnership to be successful there has to be alignment around principles, values and the quality of healthcare delivered between organisations in a way that is consistent across the wider health and care system.

The journey continues and, while we are not sure where it will end, we do know that through the Guy’s and St Thomas’ Healthcare Alliance approach there is potential for real strength and genuine excellence, stability and sustainability for the organisations involved. Guy’s and St Thomas’, as the largest of these organisations and as a tertiary referral centre, has an essential role to play. However, success is dependent on the quality of relationships developed between Guy’s and St Thomas’ and partner organisations, crucial to the establishment of the effective and high quality offering mentioned above.

Measurement

It has been a challenge to track the quantitative benefits of the FHG due to the different information management systems used by Guy’s and St Thomas’ and Dartford and Gravesham. However, clear achievements delivered through the Vanguard programme have been seen. Positive patient feedback has been recorded across the three clinical workstreams, and 37,000 patient travel miles were saved between November 2016 and December 2017. For the same period, 853 appointments were held at Dartford and Gravesham instead of Guy’s and St Thomas’,5 bringing care closer to home for patients.

Metric development5

Robust and easy to collect data to support improvement allowed the FHG workstreams to understand the impact of changes made. For the clinical workstreams, collecting this data was essential for designing or implementing new pathways. Recruiting an analyst to support the FHG was challenging as existing trust information teams did not have spare capacity. This role was introduced in summer 2017.

5 For both of these metrics these data include only the UA Scan clinic (Vascular) and only the valve clinic (Cardiology)


Vanguard voicesVanguard Voice – Improving services through collaboration

Karen Costelloe – General Manager, Dartford and Gravesham NHS Trust

My involvement in the FHG started in May 2016, while I was the General Manager for Surgery and Critical Care (which included both vascular and outpatients). Although my role changed in July 2017, through my new role in the Dartford Health Partnership I have still been involved in developing the terms of the service level agreements (SLAs) around the Vanguard programme.

I was involved in working out how best to resolve logistical problems to allow the services to develop through the Vanguard programme. The crux came when the POPS clinic needed to be established and we had to consider the operational logistics for establishing a clinic within a very tight timeframe. The Vanguard programme accelerated service changes which meant that the pace of change could be quite challenging.

Through participation in the Vanguard programme we had the opportunity to share learning and practice. At Dartford and Gravesham we weren’t getting care of the elderly physicians involved with our laparotomy patients enough and this was reflected in the national emergency laparotomy audit (NELA). You could immediately see that POPS could help resolve some of these challenges and would benefit patients.

We focused on the role of nurses within the POPS service initially and created a clinical nurse specialist role which gained a lot of clinical engagement. The two POPS registrars engaged very heavily with geriatric and surgical colleagues. This encouraged a strong understanding of the model and a great willingness to move it forward.

The programme clarified and helped to streamline what was being done, how it was being done and by whom it was being done. We’ve had vascular services on this site for many years, but we were able to develop and streamline patient pathways through making links with the emergency department and surgical colleagues.

In terms of the future of the work, everything that we did in vascular is replicable across other services. The approach creates more enthusiasm locally and allows staff to be more innovative, but at the same time improves the standardisation of care because pathways are clearly set out. The learning from the Vanguard programme has have laid the foundations for us to carry out similar partnership working more locally with other health partners in the future.


What next?

The Vanguard programme has been running for two years and draws to a close in March 2018. Both trusts are eager for the legacy of the FHG to continue beyond the formal NHS England programme.

This will include:

• the adoption of new ways of working into business as usual through trust-financed business cases

• the creation of the Guy’s and St Thomas’ Healthcare Alliance

• participation in the Association of Health and Care Provider Groups.

“The Vanguard programme provided a framework to work within, but the next step is to have the courage to go with it”

(Sarah Morgan, Director of Organisational Development and Vanguard Programme Director, Guy’s and St Thomas’.)

Clinical workstreams

Within the clinical workstreams, the majority of projects initiated or tested have proved sufficiently successful to be funded through trust-approved business cases. These projects include:

Cardiology

• Consultant-to-consultant Skype clinics.

• Syncope clinics.

• Adoption of the treat and return policy/ ST-elevation myocardial infarction (STEMI) pathway for chest pain.

• Dartford, Gravesham and Swanley CCG are building a business case to continue the GP in-reach clinics for atrial fibrillaiton and hypertension patients.

Paediatrics

• 10 new emergency patient pathways to reduce variation in care.

• New consultant-led neurology service at Dartford and Gravesham.

Vascular

• A sustainable POPS service at Dartford and Gravesham.

• A multidisciplinary diabetic foot clinic at Dartford and Gravesham.

• Additional ultrasound angiology clinics to support the local management of surveillance patients at Dartford and Gravesham (at the time of writing this is being considered but not confirmed).

Guy’s and St Thomas’ Healthcare Alliance

A significant part of the FHG’s work has been exploring options for the model by which Dartford and Gravesham and Guy’s and St Thomas’ could best collaborate going forwards. The design of this is now complete in the form of the Guy’s and St Thomas’ Healthcare Alliance. This is an organisational model formed to provide a ‘third way’ to deliver the benefits of collaboration without the risks of an acquisition.

The mission statement of the Healthcare Alliance is: ‘Working together to bring the best of the NHS to our patients and their families’.

In order to achieve this mission, the Healthcare Alliance will deliver against four pillars (see Figure 3 overleaf):

• Delivering consistent, high quality care

• Developing our people

• Leveraging scarce resources

• Embracing innovation.


Following the design period, in March 2018 the Guy’s and St Thomas’ and Dartford and Gravesham Boards approved the establishment of the Healthcare Alliance as of 1 April 2018. Guy’s and St Thomas’ will become the lead and host of the Healthcare Alliance, with Dartford and Gravesham as the founding member. Both organisations will remain sovereign.

2018/19 will provide the Healthcare Alliance with a ‘proof-of-concept’ year. During this time, a number of initiatives will be delivered, including the following:

• The core proposition, which comprises a set of offers designed to support the Healthcare Alliance in meeting its overall mission. The offers are focused on workforce development which will underpin improvements in the quality, safety and financial position of all members.

• The existing three clinical workstreams have developed a number of service changes which will be maintained as part of the legacy of the Vanguard programme, as described above. This will be monitored through the Healthcare Alliance.

• Further clinical work to improve patient flows between Dartford and Gravesham and Guy’s and St Thomas’ are expected. Clinician-to-clinician conversations between Guy’s and St Thomas’ and Dartford and Gravesham services are becoming more frequent as the relationship between the two trusts develops.

• Dartford and Gravesham and Guy’s and St Thomas’ are considering opportunities where working together is mutually beneficial across both trusts but does not necessarily rely on patient flow. Radiology is a clinical area where both trusts have challenges with the efficiency and capacity for radiology reporting. As a result, they have identified this as an area that would benefit from proactively working together and sharing learning.

• Further tactical opportunities will be explored, such as the sharing of certain corporate functions.

Figure 3. Guy’s and St Thomas’ Healthcare Alliance four pillars of delivery

Association of Health and Care Provider Groups

Guy’s and St Thomas’ have been instrumental in forming the Association of Health and Care Provider Groups. The Association is a learning network of five acute care organisations who have come together to share learning around forming and delivering similar models of care. It exists to develop a better health and care approach for a population, based on the experiences of its members.

“Our aspiration is to be viewed as an exemplar model of a sustainable health system as a product of the Five Year Forward View”

(Dr Ian Abbs, Chief Medical Director, Guy’s and St Thomas’)

As well as creating a forum for shared learning between members, the association will support national decision-makers and other health and care organisations to understand the purpose, benefits and limitations of provider groups, helping to drive the national agenda. This collaborative approach to developing best practice is particularly critical as the consolidation of the provider sector across the NHS continues.

Conclusion

The Vanguard programme and the Foundation Healthcare Group have helped showcase that closer collaboration between NHS providers is a core feature of a sustainable NHS.

The last three years of work have demonstrated that Guy’s and St Thomas’ and Dartford and Gravesham are focused on meeting the challenges facing health and care providers – thinking creatively about how best to overcome these issues and continuing a partnership that improves patient care and increases the sustainability of both organisations. This can help the wider NHS consider opportunities for the future of provider collaboration.

If you are interested in further detail about the Foundation Healthcare Group please visit www.england.nhs.uk/new-care-models.

If you are interested in learning more about the Guy’s and St Thomas’ Healthcare Alliance then contact [email protected]

www.england.nhs.uk/new-care-models

mailto:[email protected]

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