System-based working demands collaboration, but how we do this brings numerous challenges based on existing organisational structures, funding streams and resources. Some integrated care systems (ICSs) have adopted a stewardship approach which essentially means establishing multidisciplinary, cross-organisational teams to act as responsible stewards or navigators of common resources.
Using population health management, stewardship considers the most effective interventions to improve value and deliver the best quality care, moving away from traditional, siloed ways of working.
Data stands at the forefront, critical for both enhancing understanding of population needs and rigorously evaluating performance, thereby driving the substantial cultural transformation required.
Data-driven direction
When Mid and South Essex (MSE) ICS established its first stewardship groups for six key service areas, Arden & GEM worked with the team to establish performance dashboards for each group.
These were designed to show performance against the Triple Aim duty – better health for everyone, better care for all and efficient use of NHS resources – as well as metrics to measure the outcomes of each care area, incorporating data from all major providers. Adopting a collaborative, iterative approach to agreeing the specification for these dashboards was as important as the outputs themselves.
Coordinated by MSE integrated care board’s (ICB) assistant medical director, and supported by our business intelligence analysts, stakeholders from individual care groups were engaged in deciding what information would be presented, and how, leading to the creation of a suite of dashboards to enhance the flow of information across the ICS.
Each of these stewardship groups is now able to track and monitor progress, including activity data, deprivation and demographic breakdowns, and patient outcomes such as improved cancer diagnosis waiting times and targeted support for frail patients. What makes this so crucial are two interlinked elements:
- The holistic approach, incorporating multiple data sources across ICS providers providing a true picture to inform decision-making
- System-wide access to data that directly demonstrates and validates the stewardship approach.
For collaborative, cross-organisational working to be prioritised and sustained, we need tangible evidence of outcomes to enable ICSs to do more of what is working well and adapt where needed to address shortcomings.
Using data to understand and transform care
But this is not just about monitoring performance. Improving the quality of data and actively using it to enhance care is what will really drive sustainable change within the NHS and social care, as demonstrated by MSE ICS’s Ageing Well stewardship group in its work on improving care for patients with dementia, frailty and adults nearer end of life.
The health and social care stewards across the group quickly identified that outdated datasets were not telling the true story for these patients, who typically represent the largest source of demand across health, mental health and social care.
Working with Arden & GEM’s business intelligence team, MSE has developed a new data capture methodology to measure best practice quality metrics for frailty, dementia and end-of-life at population health management level from all major providers. Experts, including ICS ageing well stewards, frailty consultants, community teams, primary care and dementia leads have co-created a quality improvement tool called Frailty End-of-Life Dementia Assessment (FrEDA). This tool measures and records frailty and enables delivery of seven high impact personalised care inputs, including falls risk assessment and structured medication reviews.
Alongside FrEDA a single ICS-wide register for frailty was developed – the Electronic Frailty Care Coordination System (eFraCCS). This feeds into an ICS performance dashboard enabling whole system monitoring to drive quality improvement for every provider. Auto referral frailty register prompts have been built into every provider’s electronic patient record, while training modules have been rolled out across partners, including local authorities.
FrEDA is now in use across 27 PCNs, community teams, dementia teams, hospices and secondary care. Early results show increased evidence of collaboration across partners with a growing range of referral sources to eFRaCCS as partners utilise the system. Through a combination of improved understanding of this patient cohort and the more personalised, proactive approach enabled through FrEDA, early data shows strong benefits.Thirty-day readmission rates for older people have consistently reduced, while the percentage of over 75s incurring three or more unplanned admissions in the last 90 days of life has almost halved across the ICS.
FrEDA and eFraCCS datasets are driving more proactive care and safer, more appropriate interventions. For example, the Frailty Consultant Hotline (which provides urgent medical support to clinical teams) is using better frailty scoring in urgent care models to enable higher quality clinical diagnosis and decision-making, saving nearly 7,500 bed days in six months.
Supporting drivers of change
Stewardship is still a relatively new approach within ICSs, challenging embedded ways of working that have been in place for years. But just as we are becoming more adept at multidisciplinary working and more accustomed to population health-based collaboration, so we are rapidly advancing our use of data.
Whether it’s about understanding the problem, identifying solutions or developing tools which support both, there is no doubt that effective insight and performance management data are crucial for future success. To build trust, we need a shared understanding – a complete picture of the environment we are operating in. To maintain momentum, we need to evidence impact.
Capturing and presenting meaningful data not only bridges gaps between partners but also facilitates a cohesive effort towards achieving the Triple Aim.
By Aaron Atkinson, Associate Director of Business Intelligence at NHS Arden & GEM and Dr Peter Scolding, Clinical Director of Stewardship at Mid and South Essex Integrated Care System
