INTEGRATED CARE

Mark BrownAxel Nemetz Andrew Morley

A Collection of EssaysNick Bosanquet & Murray Ellender Jeremy TaylorRichard Fluck Peter Brambleby

INTEGRATED CARE

Mark BrownAxel Nemetz Andrew Morley

A Collection of EssaysNick Bosanquet & Murray Ellender Jeremy TaylorRichard Fluck Peter Brambleby

With a foreword by Norman Lamb MP, Minister of State for Health

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CONTENTS

7 Preface

8 Background of the Group

10 Introduction by Harry P Keenan

11 Foreword: Integration is the future by Norman Lamb, Minister of State

15 Health Services: Integration at the earliest stage – Nick Bosanquet and Murray Ellender

23 Integration needs an integrator: the role of the health and wellbeing board – Dr Peter Brambleby

31 Thinking afresh the NHS – Mark Brown

43 Integrating patient care for long-term conditions; the example of kidney failure – Ian Hazel & Richard Fluck

55 Lessons on integration from Criminal Justice – Andrew Morley

61 Integrating patient care for long-term conditions; telecommunications, telemedicine and telehealth – Axel Nemetz

69 Joined up care – a patient and carer viewpoint – Jeremy Taylor

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PREFACE

The 2048 Group, facilitated by Baxter, has been very easy to chair. Its members have displayed a wonderful commitment in bringing their expertise, experience and independence to the benefit of the public policy debate. Summarised in this document, their presentations explain not only why but also how to overcome the traditional differences between health services. They make an independent and clinically-led case for change. They look forward to engaging on the wider policy community on these ideas and on their future work.

Andrew Haldenby Director of Reform

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BACKGROUND OF THE GROUP

The members of the 2048 Group come from a range of backgrounds and are united by their passion for the NHS. Assembled by Baxter Healthcare and chaired by Andrew Haldenby of Reform, this diverse group is characterised by its lively, solutions-focused debate of some of the key issues facing healthcare in Britain today.

Since its inaugural meeting in September 2011, when integrated health and social care, and the treatment of long term conditions were chosen as focus topics, the Group has worked hard to advance its initial ideas, drawing on the views of a wide range of stakeholders including clinical practitioners, policy makers and patients. Analysis of how adjacent industries have approached integration has given the group a unique perspective and a heightened understanding of some of the key challenges involved in addressing this important issue.

Keen to deliver some tangible outcomes from its discussions, the 2048 Group has compiled a book of essays picking up some of the key themes and insights that have been developed around integration. Selected members and guest contributors have written essays on a range of integration-centred ideas, ranging from the role of telehealth solutions in providing integrated care and the need for improved communications between primary and secondary care, to lessons learned from the integration of the criminal justice system.

Sincere thanks and appreciation go to Dr Peter Brambleby who collated and edited the essays. All authors’ views are their own.

Members:

• ChairAndrew Haldenby, Director of Reform

• FacilitatedbyBaxter Healthcare Limited

• Dr Peter Brambleby Former Director of Public Health for Croydon

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• Dr Nick Goodwin, PhD, FRGS Senior Fellow in Health Policy at The King’s Fund

• Professor Bernard Crump Former Chief Executive, NHS Institute for Innovation and Improvement

• Jeremy Taylor Chief Executive of National Voices, the national coalition of health and social care charities.

• Dr Richard Fluck Consultant Renal Physician, Royal Derby Hospital and Clinical Lead, East Midlands Renal Network

• Dr Murray Ellender General Practitioner and Partner in the Hurley Group, a primary care organisation in London.

• Professor Nick Bosanquet Professor of Health Policy Imperial College

• TheLateSteve Collins Department of Health’s Director of Policy for Informatics

• Amanda Woodall Neuromuscular Specialist Nurse working in the Greater Manchester Neuroscience centre

• Simon Keady Principal Pharmacist at University College London Hospitals

Guest Contributors:

• Mark Brown Managing Director, The Dolphin Index

• Axel Nemetz formerly Vodafone Head of mHealth

• Andrew Morley Director, Juice Advisory and Visiting Fellow at the Institute of Criminal Policy Research, Birkbeck College

Whilst Baxter funded the cost of the meeting, no fees were paid for attendance and all members gave their time and expertise in the interests of the common purpose.

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INTRODUCTION BY HARRY P KEENAN General Manager UK and Ireland Baxter Healthcare Ltd

The NHS has and continues to dominate the headlines over reform and reorganisation. Now it’s time to move on and look to the future. The NHS is working on a new Vision, which in essence is it’s view of what it needs to deliver for the patients of today and tomorrow. The NHS is a great institution but has become institutionalised and siloed. However it is simply too great and important ever to fail.

Leaders within the NHS talk about how now is a time for ‘targeted disruption’ the need to work in different ways, to ensure that better outcomes are achieved for patients. The voice and empowerment of the patient is the fundamental element of integrated care. As one of our essays suggests “Patients should be the controller and coordinator of their condition drawing on clinical and other support to assist their choices.”

Our group of diverse and eminent thought leaders, has taken time to listen and share their expertise. They have used this forum as a place to make statements and generate ideas for the future.

The discussion at each meeting was rich with thought provoking ideas and challenges. We were challenged to think about the NHS not as a great whale, but as a shoal of fish, swimming in the shape of a whale. I remember being invited to think about the framework for integrated commissioning by saying it slowly – “Co-mission-ing” – sharing the mission to achieve health and well being. Also commissioning for populations and for health and wellbeing is different from simply paying for episodes of care to individuals.

We were reminded that we can train people to become more “can do” but that we should never waste a good crisis!

The group has been a real pleasure for Baxter to facilitate over the past year. We hope that this collection of essays will not only help influence change in the NHS but also be the first of many outputs from this group.

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FOREWORD: INTEGRATION IS THE FUTURE

Our country is changing. People are living longer and doing more. That is testament to advances in public health and to the high standards of our health and care services, but while life expectancy has increased, quality of life has not always followed at the same pace.

Although many people live well into their old age with immaculate health, the number of people with acute and chronic, often multiple, health conditions is going up fast. We know there are 15.4 million people in England with at least one Long Term Condition and those with more than one is set to rise from nearly 2 million to 3 million between 2008 and 2018.

We have put a greater emphasis than ever before on preventative care and self-management across a range of long-term conditions. But however well people manage those conditions, there is nearly always an impact, however small, on health and social services.

The financial challenges facing the NHS and social care, combined with the increasing demand for services, mean we need new, more integrated forms of services. The challenge is to break away from the obsolete working practices of yesteryear and embrace new ways of working.

The twentieth century was the age of the hospital. Great new buildings sprung up around the country and, through the advent of the NHS, revolutionised healthcare in Britain. But the twenty-first century will be the age of more community treatment, as new technology means people often don’t have to go to hospital to be diagnosed, treated or cared for.

Yet while we are increasingly referring to the need for integrated care, the term remains vague for many. What services need to be integrated? What are the advantages of integrated care? Who will benefit the most? What must policy makers and practitioners do to integrate care in the first place? These essays will provide answers to some of those questions.

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We can also learn from other sectors. As ‘Lessons on Integration from the Criminal Justice System’ illustrates, language, focus, accountability, autonomy, analytical capability and persistence are all critical to developing an integrated system, whatever it will eventually be used for. We have to be open to those lessons.

Integration offers genuine benefits for patient and service users. As National Voices has pointed out, a lack of joined up care is one of the biggest frustrations for patients. Integration offers seamless, person centred care, with a smooth transition between services. As this compendium emphasises, “patients should be the controller and coordinator of their condition drawing on clinical and other support to assist their choices.” They should also “be the pivot around which integration revolves”.

And revolve it does, a lot wider than just health and social care. There are many different things that affect the quality of our lives, like housing, education and transport to name but a few. Progress will therefore rely on good partnerships across the NHS, public health, local government, the voluntary sector and indeed communities themselves.

As one essay puts it, “integration needs an integrator”. I think that Health and Wellbeing Boards offer a way to integrate lots of different local groups and partners, many of whom rarely worked together before until now. They will bring together experts in education, employment, environment and housing as well as health and social care.

Integration is about local partners, working together to find local solutions to local problems. That said, there is a role for central government. We are responsible for the incentives and legislation that encourages integration.

We are addressing these responsibilities and reinforcing them through the NHS Constitution, the Mandate to the NHS Commissioning Board and the Outcomes Frameworks. The Common Purpose Framework for integration, which we detailed in our Care and Support White Paper, will be developed with and by our partners in the health and care system. By Spring 2013, we will have outlined our future plans for integrated care.

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I am delighted to be able to commend this collection of essays to you. They draw on the expertise and enthusiasm of the 2048 Group and other key thinkers and illustrate the new solutions to old challenges, which can be made to fit all sorts of local circumstances and needs.

I am looking forward to working with you to develop integration and improve care.

Norman Lamb Minister of State

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HEALTH SERVICES: INTEGRATION AT THE EARLIEST STAGENICK BOSANQUET AND MURRAY ELLENDER

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Nick Bosanquet is Emeritus Professor of Health Policy Imperial College, Associate Volterra Consulting and was Special Advisor on Public Expenditure to the Commons Health Committee from 2001 until 2010.

He was a member of the UK Government Advisory Group – Reform Cancer Strategy 2007–8.

Publications include: Family Doctors and Economic Incentives and The Economics of Cancer Care. (Cambridge University Press paperback 2011).

Murray Ellender is a General Practitioner and Partner in the Hurley Group, a primary care organisation in London. The group runs 19 NHS GP services in the capital, caring for 75,000 registered as well as 180,000 walk in patients per year. Murray is operational lead for the group.

Murray has a background in Emergency Medicine and has maintained his interest in urgent care services. Apart from being a provider of NHS GP Walk in and Urgent Care services, he also Co-Chairs the Urgent Care Programme Board in Inner North East London.

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HEALTH SERVICES: INTEGRATION AT THE EARLIEST STAGE

KEY POINTS

• Life expectancy in the UK has increased but quality of life has not always followed.

• Better, and more integrated care centred around general practice is probably the right solution in a UK context.

• The challenge for general practice is considerable, not least in terms of governance, incentives, leadership, learning, evaluation, the enhanced “provider” role and new “commissioning” role.

• This article looks chiefly at single conditions, but in reality co-morbidity is the norm, so integration between disease areas and clinical specialties will be an additional challenge.

• Much greater emphasis will be needed in future on prevention and maintaining independence, but the contribution of care and support will still be there.

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THE FUTURE OF HEALTH SERVICES

Health professionals are living with paradox. The financial future is dark but the opportunities to reshape health services are bright.

The new challenge is to provide improved health and social care for ever greater numbers of patients with long term medical conditions. This may seem impossible, but evidence suggests that better results are eminently attainable. So the true challenge is to break away from obsolete patterns of service and start to innovate.

In the last thirty years there have been vast improvements in survival rates. The premature (under 75 years) mortality rate has halved in the UK and overall mortality has fallen by 70 per cent. Yet the proportions reporting restricted activity as a result of disability, as in most developed countries, have shown little improvement and remain around 40 per cent. We have improved survival, but in those survivors who have long term conditions their quality of life has not improved by very much.

New models of care have been emerging out of practice – for example from national strategies for coronary heart disease and Human Immunodeficiency Virus (HIV)-related conditions. These new models evolved from successful attempts to improve outcome and contain costs and involve a four stage approach:

• Prevention• Early Diagnosis• Active Treatment• Care Programmes

PREVENTION

There is now clear evidence that risk reduction and life style change can reduce morbidity. This has been demonstrated in Scandinavia1 and is evident from the results of smoking cessation programmes. It proves that the social demand for healthcare can be contained – it is only infinite if provider incentives make it that way.

Primary care has a key role to play in delivering the prevention agenda. We have already seen that risk assessment scores at point of patient registration can identify alcohol problems and offer early intervention. Public Health must use community based services to realise their vision – the network based model of childhood immunisation that has been developed in Tower Hamlets has achieved almost universal vaccine uptake in one of the most deprived communities in England.

But general practice needs to be much more innovative. More needs to be done to encourage self care at the point that most patients first encounter the health system. Health score cards online need to be readily available. Symptom checkers and quality assured self help advice needs to be signposted via practice websites, or via other patient portals, such as www.myhealth.london.nhs.uk.

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EARLY DIAGNOSIS

In Coronary Heart Disease identification of risk factors has shown that it is possible to improve outcomes. Ancel Keys and his work fifty years ago on the impact of high cholesterol has been completely vindicated. Gains from earlier diagnosis are now clear in all major disease areas—cancer, heart disease, stroke, AIDS related conditions and others.

Early diagnosis starts with the delivery of high quality primary care, but relies on close links to secondary care colleagues. The communication channels need to be open. Two-week-wait referrals are a success story, but paper based communication remains ‘the norm’ and this needs to be addressed.

Earlier diagnosis of HIV can be achieved with greater uptake of near patient testing and this needs to become routine in primary care. After diagnosis, we need to shift the care of stable HIV patients into the general practice setting, treating HIV as we would any other long term condition – delivered by specialist nurses in the community, supported by both GPs and by Consultants in community clinics or remotely via teleconferencing2.

ACTIVE TREATMENT

The coming of minimally invasive treatment and improved diagnostics has made treatment much more accessible and lowered costs per case making it possible to improve access to care. Procedures, such as cataract operation and cardiac procedures, which were costly and difficult in the 1960s generating long waiting lists and resulting in impaired outcomes, can now be carried out on a day case basis. The insertion of coronary artery stents on a day case basis has substituted for 60% of the longer and more dangerous coronary artery bypass graft (CABG) operations.

The GP as commissioner can help to deliver the third component – active treatment. Services need to be redesigned to improve outcomes. Stroke is an excellent example – GPs as commissioners need to drive the realisation of super-specialist centres.

GPs as providers need to actively manage risk factors. Stroke incidence fell by 30% between 1999 and 2008. Stroke mortality fell from 21% to 12% in the same period. Improved identification and active management of risk factors in primary care has been cited as ‘likely to be a major contributor to this improvement’.

CARE PROGRAMMES

Improved outcomes from active treatment have created a new challenge for case management. The longer term experience means that communication with patients becomes a much greater part of care. Unless patients take responsibility for their own management, costs of repeated consultations will put pressure on service standards.

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Market models that reward consultations rather than patient autonomy or outcome only exacerbate the problem.

This approach is the core of the more successful programmes. In Finland the use of low cost prevention programmes has turned one of the unhealthiest populations in Europe in North Karelia into one with the lowest mortality. Finland has also reduced hospital use for chronic obstructive pulmonary disease (COPD) patients by 38% with a ten year use of a similar strategy.

The new models show that two very long running problems can be controlled – demand and cost. It is the often heard view that demand is infinite. In systems that use the new approach, demand can be controlled. For example, in Sweden hospital admissions rose 1% from 2000–2009 compared to 36% in the same period in the UK. Then there is the need to contain costs. Even in the US, the world champion in healthcare cost escalation, total spending on coronary heart disease treatment has fallen in the last five years as a result of statins reducing disease and stents reducing the need for re-operation.

The new approach points to a move towards out of hospital treatment. The twentieth century was the age of the hospital. The twenty-first century will be the age of near home based treatment, backed by virtual communication to specialist centres.

Care programmes are best co-ordinated by the clinician who has access to the entire health record – currently the GP. But communication channels need to be extended to include the patient. Patients need to ‘own’ their records. They need to be able to access them readily online, and be able to email and consult via webcam with both their primary care clinician, and with their specialist.

We need to move away from the twentieth century model of GPs seeing 18–20 patients face-to-face in a morning surgery. We need to adopt other systems which allow patients different ‘touch points’ with the clinician – GPs in a morning might only have seven face-to-face consultations, then seven telephone or webcam interactions, then seven electronic consultations (via e-mail or secure messaging).

We need to spend longer with long term condition patients, holding virtual clinics and virtual ward rounds remotely across a health network. We must develop innovative programmes for mental health care – easy access to psychiatry and talking therapies for patients remotely or for clinician via electronic clinical communities.

This requires a digitally adept general practice, with improved communication across health networks. Investment in primary care, increasing its capacity is essential to deliver this vision. Secondary care is ready and willing to support the shift. Integration is the key.

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INTEGRATION: THE KEY

High quality primary care differentiates us from other global health systems. Good general practice deals with high volumes of care at low cost, managing the demand for investigation and specialist opinion.

However, perverse incentives within the current system have distanced primary from secondary care. Payment by Results discourages the dialogue between GPs and Consultant colleagues and ‘pulls’ patients into hospital. This new divide is not limited to primary/secondary care – links to social care, community services, such as district nursing, and between primary care teams have been eroded. Technology developments have been astounding, but the legacy is too many systems developed in isolation. Only by re-establishing the links will we deliver the shift to out of hospital care. We need to restart the conversation. We need to join up the dots.

REFERENCES

1. Puska P. The North Karelia Project: 30 years successfully preventing chronic diseases. Diabetes voice. May 2008. pp 26–29.

2. Halve It coalition. Early testing saves lives. London 2010.

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INTEGRATION NEEDS AN INTEGRATOR: THE ROLE OF THE HEALTH AND WELLBEING BOARDDR PETER BRAMBLEBY

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Dr Peter Brambleby has a clinical background in child health and 26 years’ experience in public health. The last ten years were served at Director of Public Health level in three different Primary Care Trusts: Norwich, North Yorkshire & York, and Croydon respectively.

In giving evidence to the Health Select Committee review of NHS Commissioning in January 2010 he called for greater involvement of GPs and Local Authorities which is now being realised in “liberating the NHS” and the creation of health and wellbeing boards. In March 2012 he retired early from the NHS to pursue wider interests in arts and the environment, but remains interested in offering constructive challenge and support to any individuals or organisations engaged in population health and well-being.

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INTEGRATION NEEDS AN INTEGRATOR: THE ROLE OF THE HEALTH AND WELLBEING BOARD

KEY POINTS

• There is a candidate for the role of integrator between health and wellbeing, between local authority responsibility and NHS responsibility, and between local people and their local services. It is the health and wellbeing board (HWB). There will be a HWB in every top-tier and unitary local authority.

• This is a golden opportunity to integrate “health” and “well-being” into one rounded offer, bringing together elements such as education, employment, environment and housing as well as health and social care.

• That offer can be tailored to individuals as well as to the population as a whole. Some embryonic HWBs are already well into it.

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INTEGRATED CARE REQUIRES AN “INTEGRATOR”

There are four main functions of Health and wellbeing boards and all serve to strengthen integration:

1. Integrate the understanding of health needs. The requirement to conduct a Joint Strategic Needs Assessment has survived the recent changes.

2. This joint understanding should lead directly to an integrated strategy for health and well-being, to which all participants can sign up, based on public health outcomes that have recently been refreshed.

3. This sets the framework for integrated commissioning. To understand commissioning, say it slowly: “co-mission-ing”. The shared mission is to achieve health and well-being. Delivery of caring services is a subset of that common purpose, and must not detract from investment in wider determinants of health, or from helping people help themselves. It is perfectly possible to integrate a plurality of providers, provided the mission is clear. It does not matter (in fact it helps) if general practitioners sit at the HWB as both commissioners and providers.

4. And, to round off their integrative role, the HWBs can conduct integrated scrutiny of outcomes into all parts of the system, to see if individually and collectively the parts are delivering the agreed objectives, and within budget.

Integration does not mean centralisation or conformity. The whole point of local authority leadership and accountability is to find local solutions to local needs within local resources. Those resources include local people themselves – patients, carers and communities.

Integration means inter-dependence. Integration therefore requires collaboration.

Commissioning is not something you do to a provider, it is something you do with a provider. There are obligations both ways.

There has always been, and always will be, elements of choice, competition, affordability and local political pressure in the NHS. These are not the enemy of integration. The main obstacle to integration has been the inappropriate zeal with which a tariff-based system of episodes of acute care has been implemented, in haste, without the counterbalance of tariffs for preventive work, community care or mental health, or the involvement of social care. As a result we have fragmentation (“dis-integration”) with the added complication of costs running out of control. No-one was doing prospective programme budgeting or proactive commissioning – they were merely responding to demand and paying the bills.

For the integration they wish to see, commissioners should specify programmes or patterns of care. How the providers are paid – by tariff or block contract, by activity or outcome – is a secondary issue and should not be the driver.

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THE FUTURE IS NOT WHAT IT USED TO BE

These are times of rapid change. There are dramatic shifts in public health policy and the nature of engagement between the state and society. The financial outlook is different too, and this has prompted significant restructuring and realignment of priorities for Local Authorities and the National Health Service.

Even now, the future is evolving on a weekly basis, with considerable local elaboration and interpretation. With the passing of the Health and Social Care Act (after a “pause” to “listen”) a clearer picture will emerge. It is a picture for which the outline has been sketched but local authorities and NHS bodies are free to choose the colours and the detail for themselves.

In brief, the changes are likely to be these:

• For public health practitioners: a separation of prevention (“addressing the causes of the causes”) from treatment and care, so that public health is coming out of the NHS’s responsibility and returning to local authorities’.. In that sense we are going back to the future. It was in 1974 that local authorities’ Medical Officers of Health were taken out of local authorities and absorbed into the NHS.

• For patients: greater freedom to choose their care, where they have it, who provides it, and much more information on outcomes and options. This comes alongside greater public use of social networking media and opportunities for “telehealth” and “telemedicine”.

• For general practitioners: taking on responsibility for commissioning, which means re-shaping patient pathways to meet local needs within available resources; and developing their own role as providers of care by improving standards of primary care and extending the range of better-integrated services closer to home.

• For hospitals, community services and mental health services: to move swiftly to foundation trust status, accountable to the population they serve and responsive to local joint assessment of need with a particular emphasis on care closer to home and greater specialisation in fewer centres for rarer illnesses.

• For voluntary agencies and the private sector: the opportunity to enter the “market” as providers of care, holding contracts for NHS funds with GP commissioning consortia.

• For local authorities: taking on board the public health responsibilities, functions and staff formerly vested in the primary care trust, and closer working with GP commissioners in shaping integrated health and social care, prevention, and joint commissioning.

Health and wellbeing boards are the forum at which these changes converge and are coordinated.

Life would be very dull if the future was entirely predictable.

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THE FUTURE WILL NOT BE EVENLY DISTRIBUTED

The coalition government has renewed the previous administration’s commitment to reducing inequalities in health and wellbeing. At the same time, it has declared a commitment to local decision making and freedom for providers of services to innovate and be entrepreneurial, which will lead to variations in priorities and how things are done.

Two new forces for change are being harnessed, at least with respect to health care:

• Patient (and public) choice. Empowered and informed citizens will be freer to make their own choices and with greater responsibility for their own and each others’ care, and live with the consequences of those choices.

• GP commissioning. The rationale for devolving decisions to GPs about how the NHS budget will be deployed is to make commissioning more sensitive (to needs) and responsive (to demands) and accountable (for outcomes). A measure of success for this policy must be for local variation to arise.

The challenge for the new HWBs will be to make these policy changes a force for improvement and learning, and not for division or unhealthy competition or unacceptable gaps in equality.

THE FUTURE IS NOT ACCIDENTAL, IT IS CAUSED

One of the characteristics of the coalition government’s health policy is the deliberate absence of top-down direction. The sub-title for the new health policy is “Liberating the NHS”.

Another characteristic is the pursuit of the “Big Society” concept, with greater emphasis on personal responsibility and making a contribution rather than being the passive recipient of care.

It follows that in large measure the future is what we make it to be.

The NHS is a wonderful institution, and many of the people who work in it are wonderfully institutionalised! To many, freedom has come as a real challenge, and some organisations and professional groups are asking for details, structure and certainty. It isn’t there. It is not intended to be there. It is for the service to determine at local level.

Perhaps autonomy will have to be earned. The challenge is therefore set for HWBs to prove their worth very quickly, taking their CCGs with them.

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“Health and well-being is more than the absence of illness and disability: it is the opportunity for every citizen to be all they can be, to be resilient when stresses and threats arise, and to make a positive contribution.” (Definition adopted by Croydon’s HWB in April 2011)

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THINKING AFRESH THE NHSMARK BROWN

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Mark Brown is managing director of the Dolphin Index Organisation and a thought leader on ‘open thinking’, creativity and innovation. He created the Dolphin Index, a research questionnaire that assesses whether an organization’s climate and culture are conducive to creativity and innovation: www.dolphinindex.org

He is a practical academic, researcher, consultant, author of several journal articles and books including The Dinosaur Strain and creator of the multiple award winning Ideas into Action video series. Other books include Memory Matters and Left Handed: Right Handed

He has a law degree from Bristol University, is qualified as a Barrister-at-Law (Inner Temple, London), studied psychology and tutored masters students in educational psychology at London University and has been an External Examiner for the MBA at the UK’s Open University. He was appointed as the PWC Visiting Professor of Innovation at Henley Management College (1996–2001) and remained as Visiting Professor until 2006.

Mark has advised, consulted, and presented to numerous business and academic audiences around the world about how to create more creative and innovative individuals, teams and organisations including Apple, Barclays, IBM, GSK, Nestlé, Johnson and Johnson, Marks and Spencer, the Economist Conferences, Hong Kong Management Association, Management Centre Europe, the Middle East Management Centre and Reed Elsevier.

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THINKING AFRESH THE NHS

KEY POINTS

• We need to create tomorrow’s winning culture today where all people are: » ‘Crazy’ about work » Creative » Can-do » Caring

• To help do this we need the NHS to become more ‘ambidextrous’

• Extraordinary, cash constrained, times call for extraordinary open and fresh thinking

• We need to empower people to ‘think afresh’ – within a framework

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DINOSAURS AND DOLPHINS

What animal best captures the essence of the NHS? An elephant, or a shoal of fish perhaps.

Using the metaphors of ‘dinosaurs’ and ‘dolphins’ different organisations can be placed on a continuum.

Proverbial ‘dinosaurs’ are slow, stuck with mind-sets and traditions that once had their place but not today. Employees fear new ideas they suggest will be ‘yes…butted’ to death. Employees may be psychologically retired. Bodies arrive at work. Brains and souls are left behind. ‘Customers’ or patients are rarely either enchanted or delighted with the service they receive. And amongst employees there can be a sense of ‘can’t-do’ – a feeling of disempowerment, of not being able to get things to change.

Metaphorical ‘dolphins’ exude the opposite characteristics – those found in extraordinary organisations today, of winning cultures tomorrow. People are in love with what they do. They are ‘crazy about work’. People are constantly creative in finding better, different and new ways of delighting the ‘customer’ – and all other stakeholders. And there is a ‘can-do’ culture where people feel they can take the initiative and make things happen for the better – whilst, of course, avoiding the making of stupid errors or creating of chaos. In heart and action the whole organisation’s raison d’être is to enchant, to delight the ‘customer’, along with all other stakeholders. You provide the right care for the right people at the right time in the right place.

You can find out if your organisational culture is more that of the dinosaur or dolphin – and see how your culture compares with other UK and European organisations by going to http://www.dolphinindex.org

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THE PSYCHOLOGICAL AGE OF THE BEAST

Many organisations live no longer than 30–40 years. Many perish shortly after birth or in early infancy. Young organisations that survive often exhibit a number of characteristics:

• Risk-taking is normal• There is little money• There are no organisational charts – everyone mucks in, everyone does everything• The founding team may come from very diverse backgrounds• There are no rules or systems

Organisations that have gone past their ‘prime’ often manifest the opposite characteristics:

• Risk-taking is discouraged• The organisation is usually wealthy• Organisational charts are (amazingly) complex and people can be very fussy about

protecting their particular box, their ‘turf’• Employees are less diverse, more of a certain type

Courtship

Infancy

Go-Go

Adolescence

Aristocracy

Recrimination

Bureaucracy

Death

Affair

Divorce

Premature Ageing

Infant Mortality

Growing Ageing

Founder or Family Trap

Prime

Stable

The lifecycle theory of organisations

© Ic

hak

Adi

zes

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• There are explicit detailed rules, procedures and also invisible or implicit rulebooks going back decades describing the rituals and ‘the way we do things around here’ – many of which are now out of date

Different parts of the NHS sit at different points on the lifecycle curve. The ‘beast’ overall may have many of the characteristics of those beyond ‘prime’ – with one huge exception – the organisation is no longer as rich – thus the need for extraordinarily fresh, new, open thinking to create a future that works for all. The NHS is both too great and important ever to fail. How to ensure its continuing success? (This is not to forget that the NHS is still funded at a rate that is the envy of many other parts of the world.)

THE AMBIDEXTROUS ORGANISATION: 0D–4D

The lifecycle illustration above and descriptions are based on the excellent work of Ichak Adizes, one of the world’s leading experts on improving the performance of business and government1. And as you’ve guessed what any organisation needs so as to be at ‘prime’ is the best of both lists of characteristics.

The successful organisation needs to have the best of the left and the right sides of the lifecycle – or the left and right ‘hands’. The right hand is often associated with what is correct, orderly, systematic and predictable. The left hand is more associated with creativity, chaos and is less predictable. Any organisation, if it is to thrive in the medium and longer term, needs characteristics of both hands. They need the best of control and creativity.

There is interesting and practical mileage in exploring this ‘control-creativity continuum’ – and managing for the entire continuum.

To summarise the 5 Dimensions or ‘D’s’ of the continuum:

More Right-Hand

• 0D (as in ‘overdose’) – don’t do these things – injunctions and prohibitions – critical safety and health issues – don’t kill people; critical money issues – don’t run out of cash. Don’t steer your ship onto those rocks. You don’t want to nurture mavericks.

• 1D (simple straight line thinking) – routine activities that you want to run efficiently and effectively, like ‘clockwork’ – the best of Swiss railways

• 2D (‘within the box’, incremental, evolutionary thinking) – doing everything you do ‘better’ to delight your ‘customers’ and all other stakeholders

More Left-Hand

• 3D (‘outside the box’, discontinuous, revolutionary thinking) – doing new and ‘different’ things to delight and enchant your ‘customers’ and stakeholders

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• 4D (redefines your world, a fundamental shift) – a new world is emerging and you need to spot it early to stay alive – or, if you want to be really ‘can-do’, you create this new order. For the NHS to save £20 billion you need to create a new world, you need to fundamentally rethink, to think afresh.

More Left-Hand More Right-Hand

Go-Go

Adolescence

4DNew

Paradigm

3DDifferent

2DBetter

1DRoutine

0DDon’t

Every organism and organisation needs to be smart around 0D and 1D – otherwise you perish fast – and may kill people too. If the world were static 0D and 1D would suffice to survive. In a more demanding, changing or challenging world, you need to do the 0D/1D AND look after 2D, 3D and very possibly 4D. When and how much you do of each ‘D’ depends on how your environment is changing.

Obviously you also need to think about how much of each ‘D’ you want to bring to each and every part of an organisation. And you may want to think about the extent to which to engage some or all of your people in thinking creatively around 2D, 3D, even 4D. There can be a real tension between some, or even each, of the ‘D’s. 1D is ‘Don’t sit there, DO something’. 3D, on the other hand, is ‘Don’t just do something, SIT there’.

You never want to see mistakes or failures in the 0D or 1D areas. These mistakes and errors can be ‘disastrous’ and involve untold damage. These are ‘stupid’ or ‘catastrophic’ mistakes.

If you are to have a culture that also nurtures the new, you need people to be trying things out in the areas of 2D and 3D. And because these are experiments, some will succeed and some will fail. Such successes are great. Such failures are also valuable. These are ‘glorious’ mistakes and failures. You learn and move on from these. You must be allowed to make such mistakes. In fact if your organisation isn’t having a fair number of 2D and especially 3D mistakes and failures, you are being complacent.

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Many organisational structures are more right handed, more 1D – they are uni-dimensional (straight line, predominantly top down, and arguably male or male-minded hierarchies). They are designed for productivity and efficiency – NOW. This is fine in the short term.

However if organisations are to survive for any considerable time, they need to be multi-dimensional, allowing for all the ‘D’s’ – where all parts, at least some of the time, can talk openly in a coherent way, for maximum learning, intelligence and creativity.

Along with 1D organisational life, often goes a very 1D frame of mind – busy, busy, busy, fast time. People need ‘time out’, slow time, serendipitous time, to be ‘out of time’, much more apparently ‘idle’ or ‘stiller mind’ time, especially for 3D. Time out is not time off.

So the primary structure of many organisations is 1D, the level of brain arousal amongst employees encourages sharply focused, fast, more obvious 1D thought.

BRAIN WASH YOURSELF AND OTHERS

You may use a paper or electronic map to find you way around a new city.

You have a mental map that helps you navigate your way in the world. You have evolved your map on the basis of your culture, education and experience. Your map is unique to you. It enables you to understand and make sense of your world. Without this map your world would be chaotic, unpredictable and very possibly frightening.

You need your map so as to make sense of your world; the map provides a useful, in fact essential, frame of reference. Yet, in a world of rapid change, unless you constantly revise, update and challenge your map, it will become a cage and no longer a frame of reference. You become a prisoner of your own mind. You and I become ‘dinosaurs’ wedded to outdated patterns of the past.

In this sense all of us can fall prey to that most unhelpful mental dysfunction of all time – psychosclerosis – not hardening of the arteries, but hardening of the categories.

‘Experience is valuable only to the extent that the future is like the past. In industry after industry the terrain is changing so fast that experience is becoming irrelevant and even dangerous’2.

What a coincidence we so often agree with ourselves! As Betrand Russell said ‘Most people would rather die than think; in fact they do’3.

And here’s the rub. Those who have been inside the organisation longest are those most prone to becoming dinosaurs. Many of these long-service managers hold senior, even top, positions.

We need to wash people’s brains to free them. They need to see that not all sacred cows are sacred.

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There are new and better ways of doing things. We need to help people become more aware of their assumptive universes and then enable them to create new and different ways of thinking and then acting. The often invisible rulebook needs to be made visible and explicit and then constructively challenged. Open thinking and constructive dissent are to be encouraged. Challenge one or more assumptions a day.

CRAZY, CREATIVE AND CAN-DO TEAMS

A simple way to engage everyone in thinking beyond the possibly unhelpful patterns of the past is to set up teams that are asked to think afresh everything they do and find better and new ways of doing those things (or stopping doing certain things) – and to consider those things they currently don’t do that can be initiated – all in pursuit of enchanting and delighting the ‘customer’ and other stakeholders.

You can set up such ‘Ideas into Action teams’ and give them effective blue-sky divergent thinking tools, plus convergent decision-making tools to ensure new initiatives are based on solid evidence. And you can empower these teams to turn winning ideas into action. See http://www.videoarts.com/product/IDEA/Ideas-into-action.

You can help people become more able to make winning idea happen by making them more can-do. You can train people to become more can-do4.

People may talk about the NHS as though it is some monolithic giant striding around the UK. To help people shift back from the mind-set of ‘they’ and back to ‘we’ and ‘we can make things happen’ you need to create more open job definitions, remove excessive top down controls and status symbols. Employees need to be seen as a huge asset, never just as a cost, nor informed on just a ‘need to know’ basis.

So empower all your people to be creative and can-do so as to delight and enchant the ‘customer’ and all other stakeholders. However how do you do this without creating the risk of making dangerous mistakes and creating chaos?

You empower all your people within a framework. See http://www.videoarts.com/ product/GREEM/The-green-movie

Disastrous mistakesGlorious mistakes

GOGO

THEN LET KNOW

YES THEN GO

NO GO

Can-do within a framework

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The ‘No Go’ box contains the necessary rulebook of inhibitions and prohibitions. For the ‘Yes then Go’ you must get permission from the boss before you proceed. The ‘Yes let know’ box is where you are empowered and it is useful or polite or both to let your boss know. The ‘Go’ box is total unfettered, unlimited empowerment.

The more you can drive people’s jobs into the two left hand boxes the more engaged and empowered they will feel. The ‘crazier’ they will be about coming to work. You need to give people ever-greater autonomy along with the opportunity to learn and develop so as to as to take on ever-greater levels of autonomy, responsibility and accountability.

MESTAKES AND ERORRS!

On the right hand side of the continuum you never want to see errors or mistakes – these are those ‘disastrous’ maverick mistakes mentioned above. However on the left hand side you expect to see ‘learning mistakes’ because people are sensibly experimenting and trying out new ideas – thus you get those ‘sensible’ or ‘glorious’ mistakes.

THE NHS IS TOO IMPORTANT TO FAIL

And in the spirit of ‘can-do’, for all those involved in creating the next incarnation of the NHS I will not wish you all the luck with helping this most important of national institutions – as that would be pointing the rigid digit up the backside of the gods. Instead I finish with the Abraham Lincoln thought:

‘The best way to predict the future is to create the future’.

REFERENCES

1. Ichak Adizes, Ph.D. (1988). Corporate Lifecycles: how and why corporations grow and die and what to do about it. Prentice Hall, Paramus, New Jersey

2. Gary Hamel. (April 1996) Competing for the future with C. K. Prahalad Harvard Business School Press

3. Bertrand Russell

4. Dweck, C. S. (2006). Mindset: The new psychology of success. New York: Random House

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INTEGRATING PATIENT CARE FOR LONG-TERM CONDITIONS; THE EXAMPLE OF KIDNEY FAILUREIAN HAZEL & RICHARD FLUCK

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Ian Hazel – Information technology specialist and chronic renal failure patient.

Ian Hazel is a long-term dialysis patient who was diagnosed with chronic renal failure secondary to Cryoglobulinaemic Membranoproliferative Glomerulonephritis in October 1999. He has had experience of a variety of renal replacement therapies, including peritoneal dialysis, renal transplantation, in-centre HD and High Dose HD in the home (including nocturnal HD).

He is currently a Senior Systems Manager at Chesterfield Royal Hospital NHS Foundation Trust, a Director of Millbrook Technology Solutions Limited (Fleet Technology Consultants), and Chair of Deer Park Primary School (Wingerworth) Parent Teacher Association. He lives in Chesterfield, Derbyshire with his wife and their five-year-old son.

Dr Richard Fluck – Consultant Renal Physician, Royal Derby Hospital and Clinical Lead, East Midlands Renal Network.

Dr. Fluck went to Trinity Hall, Cambridge and the London Hospital Medical College, London University

He has developed all aspects of nephrology within Derby looking at service delivery, planning, education, teaching, training and research. During 16 years at Derby, the unit under his leadership has developed into a centre renowned for the quality of research, innovation and clinical care.

Prior to Derby he was honorary senior registrar and lecturer to the medical unit and the renal unit, within the Royals NHS trust and Queen Mary Westfield College, London.

He is currently the Chair of the Kidney Alliance, the President of the British Renal Society and is country coinvestigator for the international Dialysis Outcomes and Practice Pattern Study (DOPPS). He lectures across the globe on many aspects of renal disease, but with a focus on infection, access and home therapies.

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INTEGRATING PATIENT CARE FOR LONG-TERM CONDITIONS; THE EXAMPLE OF KIDNEY FAILURE

KEY POINTS

• The patient is the pivot around which integration revolves• “Vertical Integration” is needed between the steps in

the patient journey, with a single accountable clinician in overall charge

• “Horizontal Integration” is needed between the clinical disciplines

• Health and well-being boards should oversee the integration between health and social care

• Commissioning of health and social care should specify the full pathway, from the prevention of avoidable disease through to a well-managed death in a place of the patient’s choosing.

• Home treatment, with the patient in control, is the default starting position in each treatment plan

• Integration requires a shared understanding of need, resources available, shared outcome objectives, sharing of data and joint evaluation.

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IAN’S STORY

I am a chronic kidney disease patient from Chesterfield in Derbyshire. I’m married to Emma, and have a five year old son, Laurence.

I found out about my illness purely by chance. I started a new job in June 1999 (I was 27 years old at the time) and was given a random health screen which revealed a blood pressure of 170/140. This set alarm bells ringing, and after several investigations including urine dip test, ultrasound and biopsy, I was diagnosed with Membranoproliferative Glomerulonephritis secondary to Cryoglobulinemia. Initially, I was treated with medication and lifestyle changes, but unfortunately my kidneys continued to deteriorate and I had to commence Renal Replacement Therapy in October 2003. I’ve now been a dialysis patient for almost nine years.

Over the years my experience with the condition and its treatment has been mixed but on the whole I have been able to continue to lead a full, active and productive life. I have been exposed to many of the available treatment modalities including transplant. I’m currently a home haemodialysis patient performing my treatment overnight, 6 times per week.

The care I receive from my Renal team has generally been excellent, I feel that I have been informed about what is happening to me and have been given a choice over the type of treatments available, although occasionally there is a tendency to adhere rigorously to defined pathways ignoring the individual patient’s needs.

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My feeling is that there is sometimes a lack of joined up thinking between secondary and primary care, mainly on the side of general practice. Some Primary Care Healthcare professionals seem almost afraid of dealing with problems they perceive to be related to my primary diagnosis, e.g. Stomach pains and constipation, saying that I should talk to my consultant about these, often after I have already been told to see the GP by the consultant. This leads to a feeling of being bounced from “pillar to post” and being unsure who to turn to. Communications can be a problem, sometimes there seems to be a delay in these reaching the GP surgery, meaning prescriptions etc can be produced incorrectly. There also seems to be lots of repetition between services. As a renal patient, I have regular blood tests, and have my BP taken and recorded at each dialysis session. However, I still receive regular requests from the GP to have these tests done again!

The areas I would like to see introduced or improved for the management of long-term conditions like mine are mainly centred around flows of information, education and better understanding. Particularly for conditions like Renal Failure requiring dialysis, GP practices probably have, at most, a couple of such patients and so are unfamiliar with their needs. GPs need to be able to quickly and confidently know what symptoms do and don’t relate to the primary diagnosis. I feel it would be useful to have long-term disease information and education programmes available. There also needs to be simple and timely access to basic care plans and records so that all parties involved in the patient’s care are aware of what tests and treatment are being given to help reduce the repetition, which in turn will help to lower effort and costs and improve the patient experience.

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VERTICAL INTEGRATION

At the heart of integration is an understanding of the full patient pathway, or “vertical integration”. A chronic disease such as kidney disease represents a pathway down which a person may travel. Understanding the elements of that journey are vital to improve the patient experience, maximise beneficial outcomes and reduce economic burden (see figure 1).

As an example, this article will illustrate the principles using Ian’s story and that of chronic kidney disease.

This pathway commences outside the medical context, with an understanding of healthy living and protecting good health. There are then individuals who may be recognised in primary care as having an increased risk and in whom reducing risk factors may be simple yet important. For example, diabetes is the commonest identifiable reason for someone to reach end stage kidney failure. Attention to sugar control and blood pressure at the earliest possible stage may reduce the likelihood of this and other serious complications.

Each step is important and requires partnerships between different disciplines. For example, as kidney disease develops there is a need for good dietetic information to deal with the metabolic consequences of kidney disease that are detected as the blood tests are monitored. Each transitional phase between steps is critical too. These transition points need to be recognised and systems developed to allow smooth handover. If we look at Ian’s story, whilst he is happy with his care overall, it would appear that sharing of information is not as transparent as he would like.

Patients travel sequentially along this pathway, though with good management some will not have to finish the journey with respect to a particular condition. All need an understanding of the disease, their personal risk factors, lifestyle adaptations, the treatment options and how to continue getting the most out life without unnecessary limitations. This includes discussion about the end of life. Dying is the final step on any patient journey, and this step should be approached as openly and honestly as any other.

This requires a re-orientation of roles. Ideally, the patient should be the coordinator and controller of their condition, drawing on clinical and other support to assist their choices. In support of that, clinical leadership is required for both the whole pathway and the individual steps, with clinicians “coaching” the individual. The clinical team has a responsibility to collect and share data at each stage so as to evaluate outcomes and best use of resources in a cycle of constant refinement and innovation, for both the individual and the system.

Outside this one-to-one relationship, those with responsibility for funding or commissioning – for health and social care – will need to understand the whole pathway and how it fits together. They should specify an integrated pattern of care with indicative outcomes and quality standards. They should not be “spot purchasers” of isolated episodes of care.

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Terminal phase and death

(Death from kidney failure or its complications)

Sensitive end of life planning, support for family and loved ones

Each transition

is important

Action neededSteps on the pathway

Screen for risk factors, promote healthy lifestyle

Healthy with respect to this condition, and not at risk

(Normal kidney function)

Risk reduction, and screening for known risk

factors

Healthy but at increased risk

(Eg family history/diabetes)

(Screening for damage, diagnosis of reason for damage, treatment of

underlying causes)

Detectable damage has started, though the patient

may not feel ill

(Kidney disease has started)

Assessment, treatment to protect kidney function,

preparation for dialysis or kidney transplant; advice on

job, mortgage, leisure

Function is impaired and the patient feels unwell

(Kidney function is measurably impaired)

Dialysis or transplant, and all supportive therapies,

including social, employment, housing adaptation

Long-term treatment is necessary and has started

(Kidney replacement therapy is needed)

Figure 1: “Vertical integration” along the patient pathway (eg kidney failure)

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HORIZONTAL INTEGRATION OF PATIENT AND PROFESSIONAL VIEWPOINTS

Whilst vertical integration is paramount, it is important to understand how horizontal integration between members of the renal team, other clinical disciplines and other agencies is also necessary to generate the best outcomes, best patient experience and best use of resources. For example, a patient with diabetes may need to seek advice and care from a cardiologist or a diabetic nurse specialist, whilst still being on a kidney pathway. The frustration for an individual with a complex condition may be that at times people do not seem to coordinate their care, and potentially reduce the quality of care.

The challenge is to ensure that patients receive the neccesary advice whilst minimising the perceived waste that occurs because of disjointed care. Much of this is about sharing information, joint working and allowing the patient control. For example, a patient on in-centre haemodialysis attends the hospital three times a week for dialysis, yet in many cases will attend another day if they have a problem with their feet due to diabetes. Better to arrange the chiropody appointment during their dialysis session. Or for the patient who sees their diabetologist and nephrologist on separate days when they would be better in the same clinic and working together.

AGREEING WHAT IS IMPORTANT

To the patient and the professional teams (including the clinical teams and those concerned with housing, employment or education) the objectives and measures of success may be couched in different terms that need to be brought together.

The doctor or nurse, for example, will understand the physiology, pathology and pharmacology of renal disease and be interested in empirical measurements like urine output, serum creatinine level and blood pressure. They will assess need and respond accordingly.

However, for the patient, the immediate problem may be loss of energy, shortness of breath or worries about job and mortgage. Whilst there may be a medical solution that the clinician would favour, this might affect some other aspects of the patient’s life.

It is often the case that focus is on trying to prevent the patient dying while the patient is concerned with getting on with living! Placing the patient at the centre, with an integrated care approach, recognises that shared decisions start with the person, not a single organ such as the kidney, nor the institution or the money!

There are many projects currently in development to try to match patient-reported outcomes to clinical intervention. At the Royal Derby Hospital a six-point patient evaluation tool has been developed for use by people with kidney disease, measuring symptoms along a line (“linear analogue scale”):

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1 Feeling of general well-being Very poor » excellent

2 Presence and severity of bodily pain Extreme » no problem

3 Feeling worn out or drained Extremely fatigued » full of energy

4 Sleep quality Very poor » excellent

5 Difficulty breathing and shortness of breath

Extreme » no problem

6 Appetite Very poor » excellent

This tool is called the Derby Evaluation of Illness (“DEVIL”). To turn a popular cliché on its head, the detail is in the devil!

INTEGRATION OF THE COMMISSIONING OF CARING SERVICES

“Commissioners” in this context are those who hold budgets to pay providers of services. The new commissioners for hospitals and community health services in England are the local General Practitioner Clinical Commissioning Groups (advised by a wider professional group called a Clinical Senate).

The NHS Commissioning Board is responsible for commissioning primary care services and certain highly specialised care.

Local Authorities are directly responsible for commissioning aspects of social care for adults and children, and have a role in education, employment, housing, transport and environment, but they will now also host (and chair) the local Health and Well-Being Boards (HWBBs). The HWBBs could, and should, be the integrators of the local offer to patients with long-term conditions such as renal failure, joining up the strands in the network so no-one falls through gaps.

For proper integration of commissioning there needs to be a common view of the nature and scale of need in the area (part of the “Joint Strategic Needs Assessment”), the strategy to tackle it (programme budgets and redeployment of resources to better effect), a commissioning plan (describing the integrated pathways of care, the all-important transition, horizontal integration, quality specification and data capture), and finally a regular joint appraisal of how it is all going.

Commissioning for populations and for health and well-being is different from simply paying for episodes of care provided to individuals.

It is possible, but still considered radical, to appoint a local clinician as overall clinical leader for renal health of a population, with oversight of all steps on the pathway from protecting good renal health onwards, and pulling the parties together to give

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an annual account (even if he or she deals chiefly with complex or difficult cases). It would not be a good service, however wonderful the outcomes, if significant numbers of potential beneficiaries never got to use the service, or were avoidably entering end-stage renal failure. For this expanded responsibility many clinicians would require additional help, but that help exists – it just needs pulling together around a fresh way of looking at the problem.

Just as possible, but often just as radical, is to put the patient at the centre of their own management. A good example would be testing, recording and responding to their own indicators of renal function (or diabetes, or high blood pressure), through home monitoring and back-up from a named clinician such as a nurse within the hospital renal team. Telemedicine and telehealth are there to be used. Empowering the patient, who is the person with the strongest vested interest in the outcome, would result in tighter monitoring, better health and fewer trips to the hospital. This way of working, especially with a network of key workers in support, under a single clinical lead, could and should be written into contracts by commissioners.

Treatment at home should be the default option in every treatment plan, adapting later if this fails to meet the patient’s needs. All modalities of dialysis can be considered from home. Investment in patient training, technique, telemedicine, clinical outreach and reducing the dialysis equipment “footprint” in the home can all pay dividends in the longer term. The UK is close to the tipping point where home treatment becomes the norm, but the cultural and emotional attachment to the hospital is still strong in some places.

INTEGRATING INVESTMENT AND OUTCOMES (AND MINIMISING ADVERSE OUTCOMES)

Good quality saves money and is a sound investment. The estimated annual cost of avoidable acute kidney injury in England is £434–620 million (Ref: NHS kidney care, the economic impact of AKI). The estimated annual cost of avoidable infection in renal patients in England is £108 million.

One of the roles of the commissioner for renal services, in liaison with the lead clinician, is to get a grasp of how much resource is going into the renal pathway at every step, what good it does, how it compares with elsewhere, and how it might be deployed better (before any resource is added or subtracted from the programme).

Reducing harm is an important objective in its own right, as well as cutting costs and improving outcomes. It is a good example of the need for horizontal integration. There are opportunities for reducing avoidable harm on the kidneys through better awareness and reduction of risk factors. That applies too to the harm that doctors inadvertently do through unintended effects of prescribing or fluid management in critically ill people. Then there is avoidable harm in other areas, such as infection, or the late detection of complications. A role for the clinical lead is to get onto the front foot with the rest of the clinical directors in the organisation and address the causes of renal damage rather than devote all their energies to dealing with the consequences.

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Direct costs of dialysis

Indirect costs

Collateral damage

Loss of productivity

Figure 2: Costs of dialysis – Opportunity cost to the rest of the renal programme and other potential uses of these resources

CHALLENGES: WHAT DOES WELL-INTEGRATED RENAL CARE LOOK LIKE?

• A balanced triad between patient, clinician and commissioner.• Patients have real choice and empowerment• Clinicians provide coaching, solutions and leadership• Commissioners pulling the different sectors together to focus on outcomes and

experience rather than outputs.• All parties share a common understanding of the nature and scale of the problem,

the resources available to address it, and a common approach to the solution.• Inputs, outputs, outcomes and the experience of patients and staff are actively

sought, appraised and shared: “data”, “evidence” and “narrative”.• There is an open culture of sharing and learning, continually innovating and

evaluating.

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LESSONS ON INTEGRATION FROM CRIMINAL JUSTICEANDREW MORLEY

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Andrew Morley was the Chief Executive at the London Criminal Justice Partnership – a post he held for the five years to 2011. In this role Andrew coordinated activity across criminal justice agencies and other partners to deliver improvements in the efficiency, effectiveness and experience of criminal justice across the capital.

Prior to this Andrew was a senior civil servant at the Home Office working across Active Communities and Youth Justice to Mental Health and Policing. He was also responsible for implementing the current police complaints system and establishing the Independent Police Complaints Commission (IPCC).

Andrew is currently a director of Juice Advisory, a specialist consultancy providing insight and advice on crime and justice issues, and a senior visiting fellow at the Institute of Criminal Policy Research at Birkbeck College, University of London.

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LESSONS ON INTEGRATION FROM CRIMINAL JUSTICE

KEY POINTS

• Criminal Justice is a high-volume business: 1.4 million arrests and 400,000 court cases every year.

• It is slow: 22 weeks on average to complete a case – 21 weeks in magistrates court, 43 weeks in Crown Court.

• Failure is expensive: reoffending is estimated to cost between £7–10 billion every year.

• It is complex: six core agencies are involved in criminal justice and the court process, each system being made of a series of separate but dependent processes working to their own agency and own accountability structure.

• Focus could be improved: the focus of agency activity is passing on the case to the next part of the system, rather than the outcome. It is at these points of transfer that system failings are most likely to occur. There is no meaningful focus on outcome other than government targets.

• When things go wrong it can be serious: in rare and extreme cases there can be tragic consequences, as shown by public protection failures which in some part were due to systemic failings.

• There are many parallels between the challenges of reform in criminal justice and those of integration in health and wellbeing, including: language, focus, accountability, autonomy, analytical capability and persistence.

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LESSONS FOR INTEGRATION FROM THE LONDON CRIMINAL JUSTICE SYSTEM STORY

In London, trials were taking a long time to get into court then not always going ahead on the due date. I was devolved from Home Office to support the agencies to develop an integrated response across the systems, with the remit to improve the effectiveness, efficiency and experience of criminal justice across capital.

In this, I was fortunate to work with a group of visionary and committed chief officers but there was limited analytical, policy and delivery capacity to support them to shape and deliver an end to end criminal justice programme.

The Local Criminal Justice Board, under whose remit this activity fell was, like many partnership structures, cumbersome. The supporting ‘executive’ group had nearly 30 representatives who did not all bring with them the seniority and autonomy to make decisions.

Having sharpened up governance we secured investment for a realistic criminal justice system capability that brought together civil service and agency resources. Critically, this was headed up at Senior Civil Service rank. This brought together, policy, programme management, communications and analytical capability and was able to take a holistic view.

We started with system improvement – analyzing attrition rates at each stage of the process and designing solutions. Sometimes this meant tightening up existing systems and supported them with a robust performance management regime. Others required more radical re-design. An example of the latter was the “virtual court” initiative which introduced video links between the police custody suite and the magistrates court. This significantly reduced the time it took to appear at court, the number of defendants who did not turn up at court and the number of prisoner movements. This project is worth a mention not just as an example of innovation and modern communication technology, but also evidence of an appetite for a whole-system approach. It took only 13 weeks to get this from concept to operational pilot. In any partnership environment that is very quick.

Attention then moved to reducing demand by trying to reduce re-offending. There were two significant initiatives around the adult and youth populations – Diamond and Daedalus respectively. These projects required us to extend the partnership to broader community safety partners such as local authorities. This stress-tested existing arrangements but to good effect.

Over a six-year period the project was able to demonstrate significant gains in efficiency. London went from the lowest confidence rating to the highest rating for any criminal justice area in England and Wales.

Even more significantly it introduced recognition of the importance and opportunities that greater collaboration and working together can bring.

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LESSONS FOR HEALTH AND WELLBEING

Articulate “team” and “mission”. Encourage a sense of this being a collective effort.

Language is important. We began to speak about a criminal justice service as opposed to system. In our view “system” suggested transactional whilst “service” suggested transformational. Our strapline: “Many agencies delivering one service”.

Encourage strategic focus on outcomes – brought targets together under themes of more, better and quicker.

Accountability for contribution not existence

Probably single most important issue was to have the right people with the appropriate level of autonomy for policy and resource allocation at appropriate level of governance. And that meant having genuine and meaningful chief executive buy-in.

Ensure all participating agencies contribute to strategic planning. We introduced an annual strategic planning round that culminated in locking chief exec’s in a room for two days to agree plan and resource to support it.

Provide an analytical capability that makes a compelling case for change and can then validate progress against plan. This requires resource and having a senior independent figure that can act as an honest broker and so avoid anecdotal evidence taking over.

Identify your ambassadors for change. They will not always be the most senior colleagues but those who are respected and recognise the mission and can be relied on to have impact and deliver.

Never waste a good crisis! Two factors in London accelerated progress over this period – political concern about the criminal justice system’s performance and the scale of impending cuts. Use these critical moments to harness collaboration and integration.

The London riots were another good example of agencies needing to come together to run courts well into the night to meet the demand for speedy justice.

Recognize there is no quick fix – over this six year period we barely started the process of reform and collaboration.

The key characteristics you will need are relentlessness and persistence.

“Nothing in the world can take the place of persistence. Talent will not; nothing is more common than unsuccessful men with talent. Genius will not; unrewarded genius is almost a proverb. Education will not; the world is full of educated derelicts. Persistence and determination are omnipotent.” Calvin Coolidge (1872–1933),30th president of the USA

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INTEGRATING PATIENT CARE FOR LONG-TERM CONDITIONS; TELECOMMUNICATIONS, TELEMEDICINE AND TELEHEALTHAXEL NEMETZ

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Axel Nemetz was formerly Vodafone Head of mHealth. Vodafone mHealth Solutions employs mobile telecommunications technologies to improve patient care with innovative solutions on a number of levels, e.g. by giving more control to patients via remote home care monitoring, improving clinical trials with electronic patient diaries or by improving drug logistics in emerging markets.

Axel has spent more than 15 years in the pharma/healthcare sector working for pharmaceutical, biotech, medtech companies, hospitals, health insurance companies and physician groups. Prior to joining Vodafone, he was European Vice President of Novo Nordisk, headed Rothschild’s German pharma/healthcare business and worked with McKinsey in Europe and the US for pharmaceutical and healthcare clients. Axel holds a PhD in physics from a Max Planck Institute.

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INTEGRATING PATIENT CARE FOR LONG- TERM CONDITIONS; TELECOMMUNICATIONS, TELEMEDICINE AND TELEHEALTH

KEY POINTS

• The commoditisation and consumerisation of technology led to mobile phones, computers and internet for everyone. We are now at a tipping point where the established computer, mobile phone and internet platform allows for a revolution in healthcare.

• Patients will be increasingly empowered. The technologies will allow elderly and people in need to experience remote health diagnoses and even remote treatments. Trips to hospitals or physician offices can be reduced. However, current reimbursement schemes for healthcare professionals which often require face-to-face consultations need to be adapted as well.

• In parallel, the technology platforms allow for a better social inclusion of people with limited mobility, be it because of a disease, frailty or age. Mobile telecommunication connectivity can allow these people to not only receive remote medical advice and treatment, but also connect via video conferencing calls with likeminded family and friends to stabilise and improve their social inclusion. As a result, a potential entry in a nursing home can be delayed and individuals can enjoy their freedom and life in their own environment for longer.

• The implication for healthcare professionals in ‘brick and mortar healthcare facilities’ will be an increasing need for continued education and specialisation to treat the more severe cases. The less severe ones will stay out of healthcare facilities and experience remote monitoring of their disease status. Besides the UK, countries like the Netherlands are increasingly pushing for these new models. Virtual hospitals, which treat patients at home, are receiving licenses to operate. Hospitals and individuals are receiving tax breaks or full reimbursement of devices which support remote monitoring.

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USING WHAT IS ALREADY IN PEOPLE’S HOMES AND HANDS.

Greater use of telecommunications is empowering and liberating. Patients can adapt to their chronic condition, and its treatment, by using means of electronic communication that are already part of work and leisure.

This is consistent with several strands of current policy on health and well-being.

• Putting the patient in control of understanding, monitoring and treating their condition• “Normalising” life with the condition, with minimal interference in day to day

activities, family and social life• Making this the starting position for all chronic disease management• Using the patient’s own existing communications equipment, in most instances,

with which they are familiar, and thereby reducing costs• Tapping into systems of health and social care support that are integrated vertically

(joining up the patient pathway) and horizontally (networks between professions and organisations with common purpose).

• Being a driver for change in health and social care systems, requiring them to become flexible and adaptable as other industries have in response to the communications revolution (eg music industry, publishing and games industry).

• Reducing the need for “bricks and mortar” fixed costs, and potentially reducing other costs to health and social care and to individuals.

• Potential for greater choice between systems since much of the contact is at distance. In theory, the expert at the end of the line could be anywhere in the world provided they had recourse to a local hospital for periodic face-to-face contact and management of complications.

• Improving frequency access to support for patients who are immobile, eg bed-bound, or restricted in other ways (the prison health service is a good example).

• Allowing more home working for professional such as nurses, thereby expanding opportunities for the part-time and home-working workforce (eg senior nurses who have started families and want part-time work). They could conduct their routine “virtual ward round” and be available to respond to calls from any convenient base – not necessarily a hospital.

• Increasingly, we should see patients with sufficient knowledge and confidence to assess their own condition, adjust therapy accordingly within the limits they have been shown, and contacting the key worker for confirmation as much as for a decision.

ADDING EXTRA EQUIPMENT WHERE NEEDED

In addition to existing telecommunications, there is a case for investment in technology to help testing, monitoring and treatment in the home, to communicate these to a key worker responsible for the individual, and then agree the therapeutic response between them.

Examples of additional telemedicine and telehealth equipment that are in widespread use and might be more widely deployed are:

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• Home testing of blood pressure, blood glucose, urine protein, oxygen saturation at the fingertip, exhaled carbon monoxide (smoking cessation), ambulatory heart monitoring.

• Reminders and recording of medication due and taken (reported by patient or carer)• Tracking technology – eg for patients with dementia who might “wander off”.• Alarms and alerts activated by the patient, or on automatic settings against pre-

determined parameters of immobility or vital signs.

IT ONLY WORKS AS PART OF A SYSTEM, DESIGNED AND COMMISSIONED AS SUCH

The efficient introduction of telecommunications, telemedicine and telehealth requires a system of expertise and services as back-up. It needs to be introduced at large scale, or better still as the norm.

Take for example diabetes, chronic obstructive pulmonary disease, chronic renal disease or schizophrenia.

• Every known patient with one of those conditions in the PCT area would be offered participation in the system, to a level of personal responsibility at which they felt comfortable, but it would be the default starting position for all.

• The “contract” between commissioner and provider would be for a vertically-aligned entire programme of care.

• Every patient recruited into the programme would have a named key worker, often a nurse with specialist experience, who they would meet face to face periodically (ideally, but not essentially, for example in remote communities). That key worker would be horizontally integrated into a wider team of professions and organisations for back-up, for example pharmacy, diagnostics, consultant medical opinion, housing, occupational health and benefits.

• Such key workers would have a caseload or “virtual ward” of patients to care for. Their responsibilities would be both proactive, to make systematic review of their patients (think of it as a “virtual ward round”) and reactive, to respond to inquiries and complications (as part of an on call rota with other key workers in the network).

• For practical aspects of everyday living, self-help support groups and voluntary agencies could be accessible on-line or on phone.

• Referring professionals – chiefly GPs, but possibly also nurses in the community, other clinical specialities in hospitals and their equivalents in social care, would need to understand and support this way of working. Greatest efficiencies are likely where participation is high.

• Patients with more than one significant condition (eg diabetes and schizophrenia) would be members of more than one programme. Here the GP would assume lead role for coordination and liaison, and ensure all key workers for a case had each other’s contact details.

• With sufficient volumes of cases it might be possible to offer patients choice of providers within a programme.

• Systems of the kind described here would facilitate a culture of regular clinical audit, financial audit, population outcome evaluation, research and sharing the learning.

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• The registered list would provide a sample frame from which to invite patients to participate in new treatment trials and benefit from service developments.

• Training for patients, carers and staff, both one-to-one and on-line, would be a significant element of the specification of the new service.

• Where additional equipment is needed, for example for monitoring, that cost would be part of the contract – offset wholly or in part by savings elsewhere. It may be necessary to provide mobile phones or internet access for those who lack the resources.

• There would need to a repair service and helpline for technical faults or difficulties. This is an opportunity for partnership with private sector providers of the equipment.

• Current contract methodologies and currencies will have to be re-thought. In simple “programme budget” terms the resources may be there already but the mechanism by which money flows will have to change. A payments system funded on patient visits to hospital will not work here.

• For simplicity, and to encourage integration around clinical leadership, it may make sense to have one contract for an entire disease pathway or care group, and then let that lead provider sub-contract between a wider network of strategic partners, subject to appropriate quality assurance and incentives. This would be for local determination.

• The new leader of the integrated, tele-based system would generally emerge from an existing provider, but could also be selected by a competitive tendering process. This would be for local determination and in line with national guidance on choice and competition. In either case, it is for the commissioners of health and social care, after due consultation with the users of the service and potential providers (assisted by the clinical input of the Clinical Senate, and improved by discussion at the Health and Well-Being Board), to decide. They would need to be clear about the pattern of service in which they want to invest (“the contract specification”), the anticipated numbers to be recruited (based on expected prevalence, and aiming to improve access for those not currently known or in adequate care), how much money is available (“the contract value”) and what the expected outcomes are (in patient and population terms). Contracts would not be based on activity per se but for a pattern of working. Financial incentives would be linked to patient satisfaction and improved population outcomes.

• There would be periodic review and named accountability for clinical, managerial and financial performance of the programme. An annual report would be a suitable vehicle for making evaluation public.

CONCLUSIONS AND CHALLENGES

• Very recent advances in communications technology and networks are changing how people live, work, play and interact.

• Just as use of technology has grown rapidly and organically in areas like music, where the gramophone gave way to the record player and cassette player, then the CD player then the MP3 player, iPad and smart phone, so it can be anticipated that use of communications technology in health and social care will evolve swiftly. Much of this evolution will be generated by the public or the technology companies, and providers of caring services will often have to follow rather than drive the changes.

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• Many of these developments will bring advantages, freedoms and improvements in health and well-being.

• Devices and technologies alone will not deliver the desired health benefits. There needs to be a knowledgeable and caring professional on the other end of the line, and that professional needs to be part of a wider network of expertise and support.

• Current patterns of service delivery, capital investment and staff skill mix is out of step with these huge social changes. They will have to evolve rapidly and remain flexible.

• Commissioning and financial transactions will have to evolve rapidly if they are to be an enabler instead of a constraint.

• The challenge can be summarised in these words of Charles Darwin: “It is not the strongest of the species that survives, nor the most intelligent, but the one most adaptable to change”.

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JOINED UP CARE – A PATIENT AND CARER VIEWPOINTJEREMY TAYLOR

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Jeremy Taylor is chief executive of National Voices, the national coalition of health and care charities. He joined the organisation in 2009 – a year after its launch – and has been building its impact and visibility as a major voice for patients, service users, carers and their representatives. He is one of only three voluntary sector leaders to appear in the Health Service Journal’s latest list of 100 people with the greatest influence in health policy and the NHS.

Jeremy is a member of the NHS Future Forum, the expert independent panel commissioned by the Prime Minister to advise the Coalition Government on its health reforms. He is also vice-chair of the Health Quality Improvement Partnership, the national body which promotes clinical audit.

A former senior Treasury official, Jeremy has previously been Executive Director of Groundwork East London, an environmental charity, and head of research at Social Enterprise UK.

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JOINED UP CARE – A PATIENT AND CARER VIEWPOINT

KEY POINTS

• “National Voices”, a coalition of over 130 charities in health and social care, is cautiously optimistic about the prospects for greater integration of care services.

• National Voices has pointed out that a lack of joined up care is one of the biggest frustrations for patients, and that the basis for improvement has to be a focus on the experience of the patient and service user.

• The principles for integrated care articulated by National Voices have been widely endorsed and accepted by senior managers and policy-makers.

• Patients and voluntary agencies have a greater role to play in shaping care and services.

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THE POLICY CONTEXT

Since the 2011 “listening pause” as the controversial Health and Social Care Bill made its way through the parliamentary process, the importance of integrated care has risen up the policy agenda. As the Government set out ambitious reform plans, concern mounted that the more plural and devolved health and social care system envisaged by ministers would make it harder to achieve joined up care. Advised by the NHS Future Forum and prompted by strong lobbying from the voluntary sector, including National Voices, the Government amended the Bill to give greater prominence to integration, for example in the duties of the regulator Monitor and the new NHS Commissioning Board.

Since then, the Bill in all its complexity has become an Act, and the many new bodies created by the Act are starting to take shape.

Will the new system be up to the task of preventing fragmentation and promoting integration? There are some very strong structural barriers to achieving success:

• separate funding systems for health and social care; • a long term funding deficit in social care; • lack of integrated IT; • underdeveloped primary and community services; • strong organisational cultures that favour working in silos;• financial incentives that reward hospitals chiefly for activity (we need a new tariff

structure that allows flexibility).

And there are steadily mounting pressures, most particularly the growing number of people with multiple, long term care needs that must be met from different parts of the NHS and from social services. Many worry how competition between service providers can be reconciled with integration.

Anyone looking for a big bang change that is going to address some of these problems will be forgiven for scratching their heads. A fundamental reform of social care funding remains elusive at the time of writing, and the expert recommendations of the Dilnot Commission have not been followed through. Despite the visionary DH Information Strategy published in May 2012, it is unclear by what mechanisms the NHS will scrape into the digital age. A relentless drive to develop wrap-around primary and community services closer to home is notably absent from the Government’s reform agenda. Pooled budgets for health and social care commissioning remain optional, despite the insistence of the Commons Health Select Committee that they are pivotal. Integration will be a “cross-cutting” theme for the Commissioning Board, not anchored in the Board’s complex “matrix” management structure.

It is too early to say whether the emerging health and wellbeing boards will prove to have the capacity, clout and willingness to act as the “powerful local system integrators” enthused about by Government ministers. The jury is also still out on the brand new clinical commissioning groups and on the new HealthWatch organisations. And so on.

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Should we just give up on integration, then? No! In fact, National Voices – a coalition of more than 130 charities in the health and social care space – sees cause for cautious optimism. The only way to make progress is to approach the matter from the point of view of the patient, service user and family member. National Voices members worked collectively to influence the Government during the “Pause” and identified integrated care as the most pressing of many concerns. Its “Principles of Integrated Care” were a definitive contribution to the debate. They pointed out that the lack of joined-up care is the biggest frustration for patients, service users and carers. Conversely, achieving integrated care would be the biggest contribution the health and care services could make to improving quality and safety. Patients, service users and carers want continuity of care, smooth transitions between care settings, and services that are responsive to all their needs together.

National Voices said that integrated care needed to:

• be organised around the needs of individuals • focus always on the goal of benefiting service users • be evaluated by its outcomes, especially those which service users themselves report • include community and voluntary sector contributions • be designed together with the users of services and their carers • deliver a new deal for people with long term conditions • respond to carers as well as the people they are caring for.

LOCAL VOICES: NATIONAL IMPLICATIONS

Based on evidence about people’s actual experiences of care, National Voices set out a vision of success, which gets to the heart of why seamless care is important. It included these statements from a patient perspective:

• “I always knew who was the main person in charge of my care.” • “I was as involved in discussions and decisions about my care and treatment as I

wanted to be.” • “My family or carer was also involved in these decisions as much as I wanted them

to be.” • “I worked with my main professionals to agree a care plan.” • “I had one first point of contact – a person who understood both me and my

condition – who I could go to with questions.” • “That person helped me to get other services and help, and to put everything

together.” • “I could see my health and care records at any time to check what was going

on. I could decide who to share them with. I could correct any mistakes in the information.”

• “There were no big gaps between seeing the doctor, going for tests and getting the results.”

• “I was always kept informed about what the next steps would be.” • “The professionals involved with me talked to each other. I could see that they

worked as a team.”

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• “Information was given to me at the right times. The information was comprehensive: it was not just medical, but also helped me understand the impact of my health status on other parts of my life.”

• “I know what is in my care plan. I know what to do if things change or go wrong.” • “I was offered the opportunity to become more educated about how to manage

my own symptoms. This helped me to set goals, and include them in my plans together with my main professionals.”

• “I have regular reviews of my care and treatment, and of my care plan. I am as involved in these as I wanted to be.”

• “When I was discharged from a service, there was a plan in place for what happened next. This was delivered without unnecessary delays.”

Just setting out these statements speaks eloquently of the journey that we still need to make from reality to vision and how central a genuinely integrated service is to safety, quality, personal control, dignity and a bearable life for family carers.

IMPACT

National Voices was delighted at the impact made by its Principles. These principles, and a subsequent paper for the Futures Forum on “What patients want from integrated care”, have been endorsed or referenced by most of the key players who will drive integrated care forwards. Sir David Nicholson, the King’s Fund and Nuffield Trust, who advise government, Monitor and the NHS Confederation are such examples. They have helped form what Monitor describes as “a clear consensus that successful integrated care is primarily about patient experience, and this is reflected in the framing of the integration objective in the NHS Commissioning Board’s draft mandate.

That gives hope that the patient and carer perspective will not be sidelined. Within the emerging new system there are many dedicated managers and clinicians who understand the importance of integrated care and see its centrality to improving quality in a cash strapped service under ever growing demand.

Patient and service user feedback, and the measurement of their experience, are now key domains of quality. National Voices is involved in the work to develop measures of experience that capture the totality of care, not just episodes in particular locations, as the standard measures do at present. As part of this work we might also need to forge a consensus on a better form of language that reflects people’s experience. “Integration” and “integrated care” are jargon words, capable of different interpretations. Words like “joined up”; “coordinated” and “working together” might have more resonance.

There are other significant opportunities for making progress with the integration agenda in the emerging, new health and social care systems. The new duty of patient involvement could prove to have some teeth. The social care white paper and associated draft Bill provide a focus for fresh energy being brought to bear on the rights and needs of individuals requiring care.

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The review of the NHS Constitution – an important but underused and little known document – will bring new attention to how we can best embed a culture of personalisation in the NHS – assuring the closely related outcomes of dignity, patient involvement, support for self management and a joined up service.

If the Information Strategy can be implemented in ways that focus on the human, rather than just the technical, there is hope that new technology will realise its true potential to empower patients and join up services, as it has in other walks of life.

Finally, the new commissioners will increasingly need and want to make friends with the voluntary sector. It is a vital source of information, practical and emotional support for patients and their families, a source of expertise on the design and delivery of services and very often the only people who fully fill the gaps between disjointed services.

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