Getting the providers into the room
Dr Tim Dalton, chair of Wigan Borough CCG, explains how they have brought providers into the commissioning process to ensure transformational change happens
Traditionally, we have attempted to do the small, easy things where organisational systems change slightly, rather than thinking from the point of view of how you would design a system if you were to do it from scratch.
Our aspiration is to do one or two things really well – to transform the system rather than doing bits and bobs around the edges. In order to do this, we felt strongly that we needed to involve our providers in that redesign process.
Most people in health and social care want to make things better, and all of us have been frustrated by issues of the previous system.
The commissioning part is just one step in the process, and over the past 12 to 18 months we have been working on how to have commissioners make decisions in partnership with providers to ensure that what we want to happen, happens.
The future of hospitals should be in the hands of patients and based on their needs. We need to work with patients and our hospital colleagues to ensure we get the balance optimised in the system.
A chance to rethink
This is our opportunity to start to properly rethink how we provide care.
We initially began with a very pure commissioning model where we kept the providers at arms' length during those first months of conversations.
But we started to recognise that while that was good at making decisions, it was bad for making decisions that meant anything.
So we wanted to make much more of provider input into the process to make
sure the innovations – which only providers could bring – really started to come into this.
We wanted to make sure there was a clear clinical voice, because when we spoke to our local directors and senior consultant colleagues there was often a sense of what might be right for the patient wasn't right for the organisation, and on occasions they felt stifled by this.
We created a clinical leaders group and that has allowed a voice to emerge in a safe environment where clinicians can start to put forward what was right in a clinical sense.
We have also formed a QIPP leaders group that brings together the chief executives of the three major local healthcare providers, social care and the local health and social care commissioners.
This provides a forum where we can say ‘we know what clinically makes sense' and then allows organisational perspectives to be presented on issues.
It meets every two months and allows us to adopt a whole-system, whole-economy approach to QIPP in Wigan.
What is decided here sets the direction and ambition for a QIPP ‘blueprint', which allows progress to be constructively challenged.
The QIPP group is then underpinned by a set of subgroups covering self-management, information management and technology, integrated care, modelling and finance and communications.
The blueprint holds the project leads to account and troubleshoots issues that span all projects – such as financial flow and risk sharing – and allows mutual lessons to be learned.
We have spent quite a period of time just building relationships, because all these organisations have different cultural issues and barriers to transforming services.
We can spend all the time in the world building very good technical commissioning arguments, but we must not forget to apply common sense.
One thing we have been looking at is the risk that if you start to solve problems in one bit of the system, you might be causing new problems in other bits of the system.
For example, a patient with dementia who becomes unwell in their home will need a healthcare element and a social care element, so it's about how you follow those resources around the system.
All the voices in the QIPP leaders group and clinical congress are key to making sure we are not just modifying and tweaking bits of the system, but really changing it.
It is vital to include the providers in the discussions, even if the final commissioning decision is then made behind closed doors.
Our first success
One example of where we have worked to transform a service has been around patients with suspected asthma, heart failure or COPD who often come in symptomatic, with breathlessness.
Because we do not immediately know the cause, the patient used to get sent to the cardiologist to be checked over, then they would go to the respiratory physician and so on.
The focus is now on getting it right from the start by improving diagnosis and ensuring existing patients are correctly classified and appropriately managed.
In Wigan, our mortality rates and hospital admissions for these conditions were higher than the national average.
Everyone was working in their own little sections and we were not thinking about what was best for the patient or the most efficient way to provide care.
To overcome this problem, we set up an integrated breathlessness service where we have a joint team that can do breath tests and give focused advice.
They have access to the cardiology and respiratory teams and can pass the patient back to primary care with a label and a plan.
The service is provided by a local, not-for-profit community interest company with two main services: a diagnosis and a review section.
They are both nurse-led services with strong links to primary, community and secondary care.
The diagnosis service is based in a community setting. The patient has a BNP done along with a referral form and is assessed around two to four weeks later. At the one-stop assessment the patient – dependent on the BNP, will receive an echocardiogram (with or without a consultant cardiologist review depending on the findings), followed by an ECG and spirometry. From this, a review by the nurse specialist will lead to a diagnosis – or recommendations to achieve one – along with a clear plan of action.
The review arm is based either at the same community unit, in an individual GP's surgery or at the patient's home. Prior to the launch of this service, there was a lot of training undertaken with the practice teams.
Where the review is done at the surgery, the practice team will often discuss some of the cases with the specialist following the clinic to learn more.
The service tends to focus on those individuals who have either had an admission or a deterioration of their condition, which was managed by the practice in-house.
It reviews the causes for the admission and empowers patients around self-management, help-seeking behaviour and often the simple things that can be overlooked – such as inhaler technique.
It also, by its close links with the practices, filters out patients whose presentation is unusual and where there may be a different underlying condition, and refers these patients on to a consultant cardiologist or chest physician in special sessions inside the service.
In its first two months, the new breathlessness service saw 268 patients, of which 252 were followed up and managed in primary care.
Local GPs have been at the forefront, diagnosing higher numbers of difficult cases, carrying out more case reviews, promoting preventive measures and providing care for patients with multiple conditions.
Patients now benefit from joined-up care from GPs, social care and the local hospital.
There will always be organisational issues, but a lot of the work we have been doing is around putting patients first. Have we listened to what the patient wants? Have we actually done that?
People may feel that a commissioning decision is reasonable or not for their particular organisation, but we need to look at whether something is reasonable in terms of what we are trying to achieve.
If we all have the same goals, it gives us a different perspective when we need to make hard decisions.
We have to be very clear that we are not just perpetuating the old system and running two systems in parallel – we do not want to end up double paying. Patients just want to have good-quality care that involves specialist care when it is needed.
The old system provided a lot of throughput through services patients did not need to see. By empowering other bits of the system, we retained the specialist services, which now only see the patients they need to see.
The biggest obstacle so far has been to get ‘permission' from the system to induce change that is transformational rather than evolutionary.
We now appear to have got this and hope to start more things changing soon. The main way of gaining consensus has been to return constantly to the theme of ‘what does it mean for the patient?' and to get patients into the room to ask that question and hold us to account.
While joint working probably initially slows down progression, it means that when changes are implemented they will be longer lasting and have more impact.
There has been work on urgent care, currently out for consultation, using this approach for system-wide change.
On top of this, there are shorter-term changes relating to alcohol, dementia and falls.
The big pathway we are trying to address is moving all long-term conditions into a generic pathway.
Cardiology, respiratory and endocrine diseases cover about 80% of long-term conditions, and we want them delivered by one generic pathway with a lot of specialist teams centred around it.
Underneath that would be primary care teams and above that layers of moderately specialist and then very specialist teams – for example, renal and mental health teams. And feeding into all of this is social care.
We also want to include employment and benefit advisers in there, which is something we realised was important in the breathlessness pathway.
We included some advisers in the breathlessness pathway for housing and keeping warm in winter, because we realised that was an important cause of bronchitis.
Just simply signposting people to how they could get help with insulation and heating made a big difference on health.
This is all about getting into that broader role about the different factors that affect people's health, and that is a model we want to continue with in the future.
We see our approach as GPs acting as a mirror, holding it up to all those involved in the health community and asking how we find a solution.
Clinical leadership needs to be the catalyst rather than the engine room – our colleagues in social care and local authority are as keen as we are on this.
Dr Tim Dalton is chair of Wigan Borough CCG