in it together: developing your local system strategy case ...€¦ · your local system strategy...

In it together: developing your local system strategyCase study compendium

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These case studies have been provided by leaders across the NHS working on system strategies who wanted to share their experiences. They are their honest accounts of what has worked, and what hasn’t, and aim to offer advice to others who may be trying to work through similar challenges. We plan to build this compendium over the next year.

We hope you find them useful – and thank you to everyone who has contributed.

Local leadership and collaboration

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Birmingham and Sandwell Vanguard Site

The story

In Birmingham the leaders of the community trust, the acute trust, and a large local GP partnership began working together to develop a multi-speciality community provider scheme as one of the vanguard sites. The team were willing and full of good purpose, but were struggling to negotiate on some crucial areas around risks and responsibilities.

To over come this, the leaders had a session where they each discussed and then wrote down their ‘red lines’ – the specific things they could not let happen as part of the process because they believed they were too risky for their organisation, or did not meet the goals of the programme. The leaders then shared the red lines with their respective lawyers who could objectively compare them. They highlighted that there were many similarities between the red lines, and not many differences.

This provided the leaders with a much stronger platform to work from. They now understood each other’s perspectives, ie what they viewed as the biggest risks to themselves and their organisations. This was particularly useful as GP practices and hospitals are very different legal entities. There was now a mutual understanding that these lines would not be crossed, and that the group would find a solution that meant risk was shared proportionally across the organisations.

The hard truth

You will need to have difficult conversations throughout this process if you are going to build effective working relationships. This means having frank and honest conversations.

Top tips

Agree your system goals and keep true to them. They will be your compass.

Take the time to see something from another person’s perspective, really think about what a decision could mean for their organisations.

Contact details

Tracy Taylor, Chief ExecutiveBirmingham Community Health NHS Trust [email protected]

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Establish common purpose

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Coastal Care Partnership

The story

Coastal Care is a collaboration of providers, commissioners and local authorities in Sussex. Eighteen months ago we came together with the aim of forming an accountable care system. We were clear on the aim, and willing, but were struggling to agree on the goals and outcomes. Each organisation had a slightly different perception of what this would achieve.

To overcome this, at one meeting each leader from the organisations presented a patient story they had sourced from a patient or clinician. One example, was of a lady with Alzheimer’s disease who struggled to navigate her way round the system as her condition deteriorated. This realigned everyone to thinking about the one thing everyone had in common, the patient. It reminded them why we wanted to become an accountable care system in the first place. From this they co-produced goals and outcomes that all parties were signed up to.

The hard truth

It is difficult to keep everyone engaged over a long period of time, and maintain the momentum with the same level of enthusiasm for working together. It took Coastal Care 15 to 18 months to get where they are today.

Top tips

Make a start and stick with it! At times it will be repetitive and painstaking but every step moves you closer to the end goal. It is worth investing the time in.

Check out their youtube video here: www.coastalwestsussexccg.nhs.uk/our-vision-for-integrated-care

Contact details

Marie Dodd, Chief Operating OfficerCoastal West Sussex [email protected]

Cambridgeshire & Peterborough health and care system

The story

The Cambridge and Peterborough local health and care system faced challenges, it was identified as one of the eleven most challenged in 2014, with financial and operational challenges continuing into 2015, including leadership resignations.

A cross system team was established including NHS Improvement and NHS England regional teams supported by an in house NHS Improvement Solutions Development team. The solutions development team worked with system leaders to strengthen collaboration by bringing all leaders together to focus on the short and long term options available for how they could enable future improved changes to the pattern of care whilst also addressing the scale of financial challenges across the system.

To begin this process, the team developed a scope of work capturing the key questions the system was trying to answer, carried out systematic 1:1 interviews with leaders to identify common key challenges and the range of options available using the Dalton framework, conducted data analysis, researched impacts of the possible solutions, collated stakeholder views, and reviewed previous report findings. All this preparation was used for the main system workshop in workshop materials, with materials shared in advance with system leaders.

The half day stakeholder workshop involved multiple sessions including a playback of findings to get to a shared understanding, standing group discussions including Q&A sessions involving posters around the room displaying the evidence, as well as voting prioritisation exercises using large wall posters, sticky dots, post it notes and coloured pens. All system leaders worked together in prioritising options in this workshop, with leaders agreeing the systems long term vision, and stepping stones on how to get there in short to medium term.

The hard truth

People will disagree, you have to find a way for them to understand each others perspective and move on.

Top tips

Playing back common themes on a systematic list of interview questions resulted in establishing common ground. Using open facilitated prioritisation exercises with interactive posters, multiple voting exercises and including time for system leaders to interact and ask questions between themselves, supported break down some of the barriers.

Where leaders didn’t agree, facilitated discussions alongside a scaling system to assess how positive or negative leaders were about certain options on a scale of 1 to 10 were effective to progress a short list of options.

Contact details

Catherine Pollard, Provider Sustainability Solutions Director – Integrated Care NHS Improvement [email protected]

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Arrange governance

Nottingham and Nottinghamshire County Council

The story

Multi-agency safeguarding hub (MASH) was a project to provide a single point of contact to report safeguarding concerns. The project revolved around information sharing across many different parties. It was set up with great enthusiasm but struggled to meet performance targets within the first year. An external consultancy was brought in to do a series of scoping interviews. It transpired some key questions had not been thought out at the beginning of the process. For example: ‘How do we share information and make decisions quickly so assessment teams can start work?’, ‘Which information actually makes a difference to the decision, and which professional judgement is necessary without slowing things down?’.

To overcome this the team ran a session where they worked through true-to-life case studies and the citizen journey. This meant they could highlight the areas where information needed to be exchanged and different people needed to take on responsibility. This approach emphasised focus on the patient and what governance should be in place to improve their experience of services, this moved conversations away from the internal barriers different organisations put in place.

The hard truth

Enthusiasm to get things done can be at the expense of taking the time to ensure the practicalities have been ironed out. It takes time to do this, but more time to revisit if not done upfront.

Top tips

This project spanned a wide range of organisations, including the fire service, police, and the third sector. Citizen stories were a common factor that could bring them all together.

Contact details

Debbie Sorkin, National Director of Systems LeadershipThe Leadership Centre [email protected]


North West Surrey

The story

The leaders in North West Surrey were struggling to meet performance targets for emergency care, so formed a cabinet to oversee performance. This included the chief executives of the CCG and the three main providers.

To make this work, each member had to accept that responsibility for performance was shared. No one organisation was to blame, but equally no one organisation was blameless. Each leader accepted their responsibility, and so it became a relationship of equals. The cabinet will now hold each other to account when performance drops. This can be done constructively as each leader knows responsibility is shared. The cabinet can then work together to develop solutions that support the organisation.

Similarly, there is a joint management board for local integrated care work, which takes operational responsibility for all organisations accountable for delivering services. Again, roles are equal and responsibilities are shared – each board member has responsibility for a specific area of integrated working. For example, the senior responsible officer from the acute trust has responsibility for workforce across the system. Overall, this means stronger governance for the system as roles are understood and responsibilities are shared so work is completed more efficiently and organisations are constructively held to account.

The hard truth

This takes time to build and develop trust. There may be conflict between organisation priorities and requirements of the system.

Top tips

There will be overlap of different members on your boards, but this is positive as it build stronger relationships.

Being an organisational leader now also means being a system leader as well. It is a crucial part of the role.

Contact details

Julia Ross, Chief Executive NW Surrey CCG julia.ross@ nhs.uk

Frame


Like Minded – North West London Mental Health and Wellbeing Strategy

The story

In North West London the eight CCGs and boroughs work collaboratively on key areas of transformation. In 2015 commissioner and providers agreed the need for a comprehensive mental health and wellbeing strategy. They also agreed this strategy should be co-produced with stakeholders, including clinicians and patients.

To do this the team ran exploratory ‘innovation labs’ through a local service user led collaborative. At these labs the team would provide a summary of evidence they had collected on performance across mental health. They would discuss with service users whether the data resonated with them, and what they thought the real issues were accessing and using services in the system. They would then work with service users to generate new ideas on how to tackle these issues.

The team also used local area networks to identify and reach a wide range of stakeholders across the system. The work in total spanned eight different population segments. From this, the team had an informed understanding of local issues and a shared system-wide ambition for change that was grounded in local experience.

The hard truth

Stakeholders will be eager to see change happen quickly, you will have to work hard to keep them on board over time.

Top tips

There will always be opportunity for more engagement and feedback but you must stick to deadlines and draw the line at some point.

Make sure people understand how the work is relevant to them, and to their local population, so they can understand the impact of their contribution.

Contact details

Jane Wheeler, Acting Deputy Director, Mental Health, Strategy & Transformation NWL Collaboration of CCGs [email protected]

Diagnose


Public Health Team in Kent County Council

The story

The Public Health Team in Kent County Council had the vision to create a linked dataset across all Kent’s local authority and NHS organisations. To do so they worked to build relationships with the different organisations, including GPs, commissioners and providers. At first, people were reluctant to openly share their data with so many different parties. To overcome this, the team worked to sell the concept of partnership, and demonstrate how sharing the data would benefit that particular organisation, as well as the whole system.

Information Governance (IG) was a particular issue, but the public health team used legislation as a lever, not a barrier, and identified ways the legislation supported them from a public health perspective. They used a well-established local data warehouse as a trusted third party data processor to pseudonymise person-level data from different organisations in a safe secure manner while maintaining patient confidentiality.

Through local authority Public Health leadership, data sharing has been unlocked in a way that has never been achieved before in Kent. The team are now working with almost every NHS provider in Kent, GPs, commissioners, social care, districts and fire and rescue authorities to maximise the benefit of this for patients.

The hard truth

It is hard to come to one picture of what is happening in a system, especially when different organisations in it are working separately to develop their own ‘one version of the truth’.

It can be difficult to engage organisations in thinking about data at a systems level for long term planning and transformation when they are under pressure to disinvest and cut capacity to make savings in the short term.

Top tips

IG is a critical enabler. Make sure your statement of purpose is clear, unambiguous and describes all the lines of enquiry you want to use the data for. It is likely you will discover newer lines of enquiry or other purposes in future and so you may have to revisit your standard operating procedures and seek further Caldicott Guardian approval.

Contact details

Dr Abraham George, Assistant Director of Public HealthKent County [email protected]

Leeds Intelligence Hub

The story

The Systems Leadership Board in Leeds had good access to performance management data, but lacked bespoke local intelligence on what was actually happening within their system. Leeds used their better care fund (BCF) to set up a small ring-fenced team (2.5 analysts) to carry out analysis for the Partnership Executive Board (CEs of City Council, CCGs, main providers) to aid joined-up decision-making. The team is working to understand how Leeds operates a single ‘care’ system. Using linked data it is able to provide intelligence on how the system is changing through time in terms of the supply of and demand for services. The use of modelling techniques has allowed the impact of proposed service changes to be analysed in advance.

The team can also identify and compare unwarranted variation in service provision across the city’s neighbourhoods. Most importantly the team has established good working relationships with the local providers and commissioners, and work with them to understand data and trends, and the factors that influence performance.

The team present data as meaningful information, not just reams of numbers, so leaders can actively make decisions. This information has allowed system leaders to have a new level of dialogue and discussion across the city. It supports them to decide how to spend money to deliver health outcome improvements and plan appropriate changes to tackle the most important gaps and inequalities.

The hard truth

It is hard to unlock the potential of social care data, as the existing system only collects comprehensive information on those with ‘eligible’ needs. This means it is difficult to assess the true demand for care services across the population. It is also difficult to keep the board focussed on the strategic decisions they need to make when they are under pressure to focus on certain areas of performance within the system.

Top tips

The team aims to present information graphically wherever possible, avoiding quoting absolute numbers or costs. This helps focus the conversation on the underlying trends rather than on differences in reported figures.

The team also avoids commenting on whether trends are good or bad, as this is for the board to decide. If there is information a Board member might find sensitive the team will ask their advice before the presentation.

Contact details

Tom Mason, Chief Analyst Leeds Intelligence Hub [email protected]


http://systems.hscic.gov.uk/infogov/caldicott

Forecast West Cheshire Health & Care System

The story

The finance directors in West Cheshire decided to develop a shared LTFM across the system. To achieve this the system needed to be ‘open book’ and share financial information between commissioners and providers in a way that had never been done before. Initially, there was some understandable resistance, West Cheshire overcame this in two ways:

1. A shared vision was developed so everyone understood the purpose of the work: “Viewed through a system (rather than an organisation’s) lens we will be successful if we can meet the needs of our population at a cost (from a provider perspective), that is less than or equal to the available funding (from a commissioner perspective)”

2. Organisations were allowed to retain a level of privacy and autonomy in the process. Only the top level of the LTFMs were shared publicly. An independent model was then commissioned to assess the detail underneath these.

A common goal and a respect for privacy and autonomy laid the foundations for building closer working relationships, as organisations began to trust each other. The first iteration of the LTFM has now been developed and signed off.

The hard truth

The real time and effort will be spent working to get buy in and agreement from different boards. Even after this, questions surrounding the assumptions and data will need to be worked through multiple times until everyone is agreed.

Top tips

The model will not give you definitive answers, but it will prompt you to look in certain areas.

If you do not reach a final agreement on underlying assumptions that’s ok. Compromise and work within the range of results.

Contact detailsTim Welch, Director of FinanceCheshire & Wirral Partnerships NHS Foundation Trust [email protected]

Kerry Robinson, Assistant DirectorPlanning, Partnerships & DevelopmentCountess of Chester Hospital NHS Foundation Trust [email protected]


Define system goals

Cambridgeshire and Peterborough Health and Care System

The story

The leaders of Cambridgeshire and Peterborough Health and Care System came together for a whole day workshop. This included CEs from the providers, the councils, the GPS, and the Chief Operating Officer of the CCG. The aim of the workshop was to come away with a working design for how services would be designed in the future, and the enablers required. From the beginning the attendees were split into mixed groups with provider and GP representation in each. They began with the 5YFV question: “think like a patient, act like a taxpayer – how would you deliver services in 2020?”.

The groups worked together to describe what they wanted. This was an unstructured brainstorming session with coloured pencils and big pieces of paper. Groups were given reign to discuss different ideas, and then presented these back to the groups. Consistent themes came out of this; for example, the expansion of primary and community care and the redundancy of outpatients.

The facilitator created a picture from what was said and the group reflected on this. They then focused on two big ticket clinical changes which were improved long-term conditions management out of hospital in advance of next winter (eg increased uptake of pulmonary rehab), tackling UEC flow through implementing their various UEC vanguard schemes (eg liaison psychiatrists) and 5 enabling changes looking at workforce, back office, self care, social capital in the community) they could make by 2016.

The hard truth

You will not come away with a perfect picture, or all the answers, but you must have a working design you can build on.

Top tips

Give the group opportunities to engage with the agenda beforehand, and feed back on the content on and approach. This way they will all know exactly what the meeting entails. Be prepared but be flexible; have enough activities to fill the agenda, but don’t use them if the conversations working.

Preparing the case for change is crucial, everyone must arrive with a shared understanding of the current situation. As a facilitator you need to know when to push for practical solutions, and when to let the conversation develop further.

Contact details

Catherine Pollard, Provider Sustainability Solutions Director – Integrated Care NHS Improvement [email protected]


Generate options

Healthy Liverpool Programme

The story

The Healthy Liverpool Programme has evolved from an aspirational vision to a clear series of plans for transforming the health service. The plan is for hospital care to be delivered as a single service, by single teams, across the city, to reduce variation and improve patient care. This has been made possible by a level of clinical consensus never seen before.

This was achieved by on going clinical engagement. There has always been strong leadership within the CCG, and there were lead GPs assigned to each work programme within Healthy Liverpool from the beginning. The GPs focused on benefit to the patient, and this resonated with consultants when they ran further engagement. The team also worked closely with medical directors from the different providers. The medical directors designed how ‘one service’ should be delivered, and presented this report back to their respective boards.

In July 2015, 120 senior clinicians and leaders from 15 organisations gathered for the Healthy Liverpool clinical assembly for hospital transformation, where a landmark agreement to work together towards a ‘Single service, city-wide delivery’ model around a centralised university hospital teaching campus was reached.

The hard truth

Even if you have sign up from clinicians it can still be difficult to engage trust boards. It took three years to build the necessary relationships for Healthy Liverpool.

Top tips

Everyone gets frustrated with the pace of major service change. Ensure from the outset staff understand the governance and assurance processes, and what is required to build up a case for change, an outline business case and those areas that require public consultation.

Contact details

Carole Hill, Healthy Liverpool Integrated Programme DirectorLiverpool CCGcarole.hill@[email protected]


Trafford CCG

The story

Trafford CCG have been developing the Trafford Care Co-ordination Centre (TCCC) for the last five years. The centre will be capable of reviewing and tracking all patient journeys across the Trafford health care economy. It will be key to developing a fully-integrated health and social care system.

To develop the specification for the centre the team used a competitive dialogue process which meant they could engage with a wide range of stakeholders and, where appropriate, providers. This meant they could fully specify and accurately cost a service that there were no precedents for. The engagement the team carried out with stakeholders and providers meant they could truly “test the art of the possible” and push the limits of what they could achieve.

The TCCC journey is not complete but is at the heart of fundamentally changing the commissioning and delivery structure within Trafford. It is predicted to reduce waste by 20%, reduce unscheduled care volumes by 15% and scheduled care by 10% over the next 5 years.

The hard truth

You must work hard to get true partner engagement. Trafford has multiple providers and as such has needed to engage with and secure the support of more organisations than might ordinarily be the case. This challenge, at a time of mounting pressure, operationally and financially, required constant effort and reinforcement. Trafford set up an Integrated Care Re-design Board with all the providers to keep strong partner engagement.

Top tips

It is important to engage the top team who can keep all organisations aligned with the overall objectives, and who can effectively engage with and influence partners at all levels.

Look beyond healthcare to engage with people with the skills, innovations and ideas outside of the usual NHS skill set.

Contact details

Paul Hulme, Associate Director of Corporate Services and ODNHS Trafford [email protected]

Prioritise


North West Surrey

The story

North West Surrey wanted to work with their stakeholders to define their priorities and options for change so they invited a wide range of stakeholders to a series of workshops. Crucially, these workshops included clinicians and patient representatives. At the workshops they presented the stakeholders with data on how different programmes of care were performing. Attendees used this information, and their own experience of accessing and using services, to identify which programmes they thought were a priority for the system to improve.

At the following workshop, stakeholders worked together to generate ideas to redesign or redevelop the identified programmes. These ideas were then stuck on the walls, and stakeholders used coloured stickers to vote on which ideas they thought should be delivered. This list of short options was then signed off by the clinical board.

When NW Surrey began to deliver the change programmes, stakeholders were brought in and supportive as they had been engaged from the beginning. Furthermore, this process has high objectivity as it is hard for one opinion to dominate such a large number of people.

The hard truth

Engagement with stakeholders will need to continue beyond this, when it comes to putting plans into action stakeholders may begin to get nervous about the impact of the change.

Top tips

Talking about programmes, not services, has real resonance with patient and clinicians because programmes are end to end and linked to outcomes, so people can clearly envision what this means for them.

Ensure stakeholders involved represent a wide spectrum of interested parties; including patients, the voluntary, charity and faith sectors, local authority and independent consumer champions.

Contact details

Julia Ross, Chief Executive NW Surrey CCG julia.ross@ nhs.uk

Liverpool CCG

The story

The CCG was faced with a question, should they invest in the ‘healthy lung programme’; a clinical programme to identify at-risk patients for early intervention, or should they invest in a smoking cessation programme. There were competing views from different organisations across the local system.

The team used Best Possible Value tools from Future Focused Finance to answer this question, and held a workshop with stakeholders to work through the tools. One of the key tools was the decision-making framework. This tool sets out different roles in the decision-making process which each organisation should be assigned to. These roles are:

• Recommend – can recommend a certain decision

• Agree – need to agree to the decision

• Perform – will carry out the decision

• Input – can provide information for the decision

• Decide – there is only one final decision maker

These roles are assigned and agreed at the beginning of the process. This means when the time comes for a final decision, there is no ambiguity around who has the final say, and no one can bar decisions with last minute objections. From this the team decided to invest in the healthy lung programme, and all stakeholders who had been through the decision making process were signed up to this.

The hard truth

It will be difficult to get everyone to dedicate time to this at the beginning when they want to press on and make the decision.

Top tips

Find out more at the Future Focused Finance website: http://bpv.futurefocusedfinance.nhs.uk/

Contact details

Matthew Greene, Programme Project AccountantLiverpool CCG [email protected]


Contact details

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NHS Improvement is the operational name for the organisation that brings together Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System, the Advancing Change team and the Intensive Support Teams.

This publication can be made available in a number of other formats on request.

© NHS Improvement (April 2016). Publication code: IG 07/16

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