I attended an excellent webinar put on by the Royal Society of Medicine where Dr James Kent, National Advisor at NHS England (covering for the indisposed Dr Claire Fuller) gave an excellent presentation and took questions around neighbourhood health, a flagship policy in the 10 year plan.
He opened up, very sensibly, by defining what it is we are actually talking about. He explained that it was a multifaceted initiative and understood that we, as humans, would feel the most important bit of it was the bit that was most important to us. I do think that is worth bearing in mind as we move towards engaging with the different tribes, not only within the National Health Service, but within local government services.
Neighbourhoods as natural communities
He reminded us that neighbourhoods are a natural community and therefore what looks like a neighbourhood will depend on social rather than medical diagnostic communities. He expects these communities will feel natural to healthcare teams, because these are the localities in which they and their families live. It is important that they reflect Local Government boundaries so as to facilitate working with their teams. In the development of Primary Care Trusts we used to call this “Co-Terminus”
Building connected teams
From an organisational development point of view it is bringing those healthcare teams (and here healthcare refers to every team that is seeking to influence either healthcare or the determinants of health care) into a single team, aiming to eradicate the friction of “referrals and silos”. From an NHS perspective this will also include, again in the true sense of the words, specialised teams such as those geriatric teams addressing frailty or diabetes teams that are currently based around a hospital outpatient model. There may well be some benefits in physical co-location, with benefits both in process efficiency (think one-stop shop) and communication among the developing teams.
Care closer to home and why it matters
He explained how it was important for care to be closer to home. The benefits to consumers (sorry, patients) are obvious but from a system sustainability point of view the objective is to “prevent work going into the acute sector in the first place”. This means that success needs to be measured not in inputs (e.g. appointments offered, location of care shifted) but the avoidance of non-elective admissions. There is something terribly important in the messaging here for me. Who could possibly fail to be energised by the idea of preventing patients from becoming so unwell as to require emergency admission to hospital? On the other hand, the idea that we are going to work harder so as to make the hospital finance director’s life easier….. not quite so motivating! I remember being caught out by this in the days of so-called “GP commissioning”. The plan there was broadly “we have come up with an idea of saving the hospital money”. Oh yes? What’s that? “You are going to do the work instead for free”.
He had a very pragmatic approach to discussing both the pathway to fundamentally changing the way the system works;
- Care closer to home.
- The left shift.
And the risks within the programme.
The challenge of shifting resources
As has been widely said elsewhere it would be completely revolutionary to shift the priority for funding from hospital-based care to community-based care, especially at the time where there is no money for investment for setting up new services bar the money saved from existing services. I’ve been caught out this way in the past setting up a specialised COPD service. When our performance was reviewed at the end of the first quarter there was no detectable drop in hospital admissions. My response that we could not reasonably be expected to reduce the admission risk of patients that we have not yet seen cut no mustard. It took two or three years for the work that we did in reducing the risk of patients becoming unwell in two or three years time to be seen in hospital admission rates. That is the necessary lag in realising the benefits of “left shift”.
It therefore makes complete sense to me his priorities for the National Health Service to get its part of the determinants of health well sorted. These were;
- GP access.
- The primary secondary care interface.
- Sorting out the geographies of neighbourhoods.
- Integrated neighbourhood teams supporting priority cohorts (and I think that means frail patients and high-intensity users).
- Remapping outpatients.
This works in organisational development terms, Prof Kotter would say “establish some quick wins”. In NHS resource consumption terms, every clinician will recognise the hours of time need to be spent on the identified patient cohorts. Again, my experience leads me to a warning. If cash is needed for a healthcare professional or a building in the community and there is no more cash coming in the system, then cash needs to be taken from somewhere. The identified target is the acute trusts. This means that reducing admissions is not enough, cash has to be removed from their budget, and in all service industries, not just health, that mean staff have to be made redundant. I remember in GP fundholding days one acute trust bringing an individual nurse into a contract meeting to say that this was the person that would be made redundant if expenditure was shifted to community based care! Has anyone ever seen an acute trust not successfully defend itself against anything but eternally increasing budgets?
The meeting then went on to consider, both in the presentation in the Q&A, things that may stop these benefits being realised. Apart from the usual suspects;
- Funding
- Estates
- Digital
- Contracting arrangements
There was the observation that not only do we need to create functioning neighbourhood teams out of currently disconnected teams, For thee to be a significant drop in acute sector admissions this needs to happen across the whole patch served by that acute trust. This might be really difficult. If we look at Rogers theory of diffusion there will be innovators, early adopters, early majority, late majority and laggards. Now, one can get too carried away with models but if the only game in town is reducing activity/spend in the acute sector (which it is) then as well as the operational focus on natural geographies there needs to be a strategic perspective of the neighbourhood capability development across the whole acute trust’s catchment area. There are some trusts e.g. Royal United Bath that “take” from multiple integrated care systems, which could total up to 5 to 10 neighbourhoods. To stretch an analogy one bad apple (aka “Laggard”) could spoil the whole barrel.
Funding and the reality of delivery
As you can imagine one of the themes that came up was the funding and structure of the change management teams. It seems that there is no new money to invest, all must come from the Integrated Care Boards current funding, which is the model for the current coaches. Apparently though, there is some dedicated money for new health centres announced in the budget. That will cause some angst to existing health centre users (i.e. general practice partners), who have been trying to modernise for decades.
A sceptical, but not negative, question raised was “why is it going to work this time”? The strategic answer provided by Dr Kent was that the evidence was that some individuals have been able to improve services for patients despite “swimming against the tide”, overcoming problems of working silos, incompatible records and limited funding. One could take that energy, link it with the political backing that meant central policies and legislation could be managed and be hopeful. He observed that “nobody seems to say that it’s not the right thing to do”.
What teams need to make change happen
The operational answers are the same answers that we have provided for over 1300 practices when they ask how our input is going to make their, and their patients, lives better. There needs to be a change management structure which convinces individuals that given a reasonable chance their efforts will lead to the benefits they seek. There also needs to be flexibility so that the change management program works for the infinite variety of geographies, practitioners, history and patients.
Colleagues of often heard me say that the work we do is like jazz music, the basic structure is agreed, it is the variations in the moment that separate the talented/successful from the untalented/unsuccessful. This change though requires the full orchestra not just a quartet.
