Northumberland was awarded vanguard status in early 2015 to form a primary and acute care system (PACS). Our health and social care system was already quite advanced, with Northumbria Healthcare NHS Trust delivering adult social care through its partnership with the county council since 2011. The county council and clinical commissioning group (CCG) are also co-located, which has enabled relationships to develop positively.
Northumberland was awarded vanguard status in early 2015 to form a primary and acute care system (PACS). Our health and social care system was already quite advanced, with Northumbria Healthcare NHS Trust delivering adult social care through its partnership with the county council since 2011. The county council and clinical commissioning group (CCG) are also co-located, which has enabled relationships to develop positively.
In the Northumberland, Tyne and Wear area there are six vanguard initiatives covering a population of 1.7 million people and the region is a national transformation area. Northumberland has a population of 330,000 and covers an area of approximately 5,000km2. Our county has areas of deprivation, health inequality and differences in life expectancy that are unacceptable.
What has Northumberland been learning so far on this journey?
1. Integrate your leadership
The World Health Organization1 has defined what integration in healthcare is, but for it to work there needs to be meaningful engagement of healthcare workers and a sustained commitment from senior management and policymakers. Northumberland now has senior system leaders in roles across health and social care. For instance, the chief executive of the county council is also the accountable officer of the CCG. This promotes relationship-building and moves us all away from the tendency to think in silos.
Integrated roles do not happen by chance; the process has to be intentional. That might be GPs in senior positions with the foundation trust, or GPs working with managers and consultants to solve challenges in IT or complex care. Our vanguard has helped us get a consistent message across, a rallying call to give others permission to make meaningful change.
2. Switch your focus to population health – one system, one team, one you
We know there is an over-reliance on hospitals and their beds, as if hospital is a default position when the community cannot cope with the complex needs of individuals. Re-aligning the incentives and health outcomes across all providers must be a better way to keep individuals in their own homes and communities.
Our key priorities2 are:
• Improving health and wellbeing in our population.
• Improving the quality of services and patient experience.
• Making our health system financially sustainable.
To do this, we are proposing to form an accountable care organisation (ACO) with a capitated budget and aligned health outcomes appropriate for our population.
This requires stakeholders to work together based on trust and a commitment to sustainable public services for the future. General practice has to be involved in this and 44 practices have agreed to form a county-wide federation to be the voice of general practice in the ACO.
Mental health providers also have a key place so that mental illness will have true parity of esteem.
Professor Chris Ham3 has stated that the change required will be more ‘sociological than technological’, which underlines the importance of consistent and courageous system leadership. The King’s Fund has been helping us to formulate the health outcomes we need that will sit across the health and social care system.
3. Ask the population what is important to them
Patient engagement has been essential throughout the vanguard programme and has occurred actively through patient forums, drop-in sessions and surveys. Patient co-design forums allow us to explore these initiatives in more depth and ensure we are moving in the right direction. Local evaluation of our programmes is focusing specifically on patient and carer experience. The risks of not doing this will be that the scale and pace of change will leave our population behind and lead to the greater likelihood of doing the wrong thing.
4. Develop a culture of mutuality
If we have all agreed we are all in this together, a culture of mutual dependence has to be realised and acted upon. An excellent example of this is workforce. We know there are crises in GP recruitment, GP and practice nurse retirements and in hospital specialties. However, there is an opportunity to develop new professional roles.
Through the PACS vanguard, Northumbria Healthcare NHS Trust employed 16 new pharmacists to work across primary and secondary care, to build capacity in the community as well as to improve the quality of prescribing in nursing homes and general practices. Clinical pharmacists have clinical skills that can be used to further release time for GPs. The foundation trust has also implemented accelerated nurse training with Northumbria University, shortening the training from three years to 18 months for certain groups. This will benefit the entire healthcare system.
Three GP federations made a successful bid for the creation of a community provider network, which will enable more healthcare students to gain experience in the community and, it is hoped, choose to remain there. In essence, different providers are working in a way that is mutually beneficial for the population and the healthcare system as a whole. It relies on building trust and a radical change to the culture of all stakeholders.
5. Disrupt the status quo
More than 10 years ago, Northumbria Healthcare NHS Foundation Trust embarked on planning for a new hospital that opened in 2015. It is England’s first purpose-built specialist emergency care hospital, with emergency consultants on site 24 hours a day, seven days a week, as well as consultants in a range of specialties working seven days a week. State-of-the-art diagnostics allow the delivery of rapid assessment and treatment with the aim to discharge or transfer out within 72 hours.
The three previous district general hospitals have been reconfigured into base sites that provide diagnostics, outpatient care, elective work and sub-acute inpatient care. GPs work alongside nurse practitioners in urgent care centres that also provide minor injuries care.
Introducing this was not without its problems, but recent results show
a reduction in the length of stay for the over-75s and a possible reduction in the attendance of patients with primary care problems.4 The new hospital configuration has created the momentum needed to reform other parts of the health and social care system.
6. Improving access can be a lever for engagement and change
Asking our population about their access needs has revealed a shift occurring in patients’ expectations. Balancing the needs of patients who want same-day access against those who need long-term continuity with a specific clinician is putting traditional general practice to the test. The NHS Five-Year Forward View5 clearly spells this out and the King’s Fund6 also reported that the lack of this data was one of the reasons why general practice has seemingly drifted into crisis.
In Northumberland, we undertook an activity-and-demand analysis across all 44 practices, primarily to help practices understand how they match demand with their individual and varied appointment systems. We have been able to provide funding to help practices modify or radically change their access models.
NHS Improvement has stated that a 1% deterioration in access to general practice can produce a 10% deterioration in emergency department figures. Early results4 from our access initiative across 30 practices are showing that the number of patients being helped each week has increased by just over 3,000, which equates to an extra 170,000 patients per year.
The learning in general practice about how to manage same-day demand against the numbers of pre-booked appointments has a direct correlation with secondary care and the way outpatient departments manage review appointments. Identifying and challenging the reasons for the review of certain groups of patients may allow consultants to better support patients and their GPs in the community.
7. Patients should only have to tell their story once
Our county is making steady progress towards a truly integrated record system through our chief clinical information office. This team is multidisciplinary and has worked hard to ensure there is strong clinical engagement, that information governance was implemented simply and quickly and that patients were kept informed throughout.
The benefits to patients’ safety and care were clear from the start, with the implementation of the medical interoperability gateway (MIG) giving emergency departments sight of the GP medical summary. By July 2017, 33 practices out of 44 will be on the same IT system that is already being used by community nursing, diabetes and palliative care teams. Huge payoffs are anticipated if the same IT system is adopted by the ambulatory care service, the ambulance service and nursing homes. An integrated IT system will hold a patient’s story in one place, ensure safety and promote communication between primary and secondary care.
8. Teams that meet together, work together
We are developing the multidisciplinary team much further. Some meet in practices but are much wider in their scope, involving community matrons, clinical pharmacists and community geriatricians working in care homes.
Progress is being made in identifying our most at-risk patients and developing clinical pathways that are applicable across the system, such as pathways for chronic obstructive pulmonary disease or frailty. This has come about from a shared understanding of the need for change.
9. Communities are the glue that holds things together
Health and social care providers have a lot to offer, but they cannot do everything. Our communities, which include carers and voluntary services, provide care day in and day out and are the bedrock for care in our county. Greater partnership with health and social care is the way to ‘achieve the triple aim’.
10. An organisation that scales up must not lose its humanity
Undoubtedly, we face massive challenges. Efficiencies may be possible by working at scale, but how do we scale up without losing our focus on the individual? The dangers of scaling up are that we become more remote and less accountable. We do not want to repeat the debates had in the banking sector about whether we have lost our humanity through scaling up, automation and new digital platforms.
We must keep reminding ourselves to learn from this.
Dr Robin Hudson is a GP and joint clinical director at Northumberland PACS Vanguard Programme
References
1 World Health Organization 2008: Technical Brief No. 1 Integrated health services – what and why?
2 Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, Health And Cost. Health Aff 2008:27;759-69.
3 Professor Chris Ham talk to Primary Care Leadership Group. The Collective Voice of Primary Care: Recommendation for the Accountable Care Organisation. Northumberland Town Hall, October 2016. youtube/epAwJyC2GW4
4 Northumberland PACS quarter 3 metrics- presented to the New Care models team March 2017.
5 Department of Health. The NHS Five-Year Forward View.
6 Addicott R, Maguire D, Honeyman M et al. Workforce planning in the NHS. The King’s Fund. April 2015
