sustaining change in healthcare: learning from local successes

Sustaining change in healthcare:

learning from local successes

6 May 2015

Sustaining Change in HealthcareGetting under the skin of the problem and remaining relevant to local context in the Knee High Design Challenge

Mat Hunter

Chief Design Officer, Design Council

Pop up parks

Creative Homes

Kids Connect

Framing the challenge

1

Double Diamond

Ethnographic

research

Convening diverse talent

2

Supporting trial and error

3

Staged Investment

In summary:

1. Framing the challenge

2. Convening diverse talent

3. Supporting trial and error

Thank You



6 May 2015

Sustaining change

Jane Stopher

www.dmi-diabetes.org.uk

June 2014 20

Our vision was for Lambeth and Southwark to be two of

the best boroughs to live well with diabetes…

• Strategic Priorities: Children, Primary Care, Community Care and Self-management

• Ambitious aims to deliver sustainable improved outcomes at a population level

• Strong cross organisation partnership with commissioners, providers and service-users

• Scaleable, not increase costs, clinically led and focus on what mattered to patients (Triple Aim Principles)

• Business case built on early detection, better biological control and self management preventing/ delaying high cost complications

• Scaleability and sustainability key design principles from the outset

June 2014 21

Measurement as legacy

• Lambeth and Southwark and the DMI cited as a London exemplar in London’s Blood Sugar Rush report, 2013

• Quality in Care winners for “Best CCG initiative” and “Best Cross-organisational partnership” 2014

• Chair of Voluntary Group, highly commended, NHS Participant of the year, 2014

• The Commonwealth Fund, case study 2014

• IHI presentation, 2015: “Achieving triple aim in inner London”

• External economic evaluation (OPM)

• Direct reductions in service delivery and indirect benefits from long term health improvements.

• In total, savings are expected:

• £1.34m in year 1 (ranging from £933k to £1.68m).

• £10.10m over the next 5 years(ranging from £5.54m to £14.13m) and

• £29.38m over 10 years(ranging from £12.25m to £45.40m).

June 2014 22

How do you measure a system of excellence?

June 2014 23

Focus the system on population health:

• The combined register size has grown by 23% since 2009/10; 16.6% since 2010/11.

• While growth over the past year slowed to 3% (compared with 9% the year before), this still represents around 800 additional patients on the registers.

Lambeth

Southwark

10,000

11,000

12,000

13,000

14,000

15,000

16,000

2009/10 2010/11 2011/12 2012/13 2013/14

Lambeth and Southwark diabetes patient registers 2009/10 to 2013/14

June 2014 24

Focus the system on flow through care settings: Specialist

diabetes care in the community

0

50

100

150

200

250

300

350

Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4

2011/12 2012/13 2013/14

Outpatients: GP-initiated 1st attendances

Lambeth CCG

Southwark CCG

020406080

100120140160180200

Qtr

4

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

Qtr

4

2010/11 2011/12 2012/13 2013/14

Nu

mb

er

of

em

erg

en

cy a

dm

issi

on

s

Emergency Admissions - Primary Diagnosis: DiabetesLambeth & Southwark registered patients

GSTT & KING'S

June 2014 25

Self-management as a system change

June 2014 26

Setting Minimum Standards for care

planning enabled routine adoption

• 2013/14 data are numbers of care plans coded with GP systems

• Assessment of quality is included in Southwark CCG scheme in 2014/15

• Care planning advocates quality assure in eye screening services

17%

39%

0% 10% 20% 30% 40% 50%

Lambeth & Southwark

combined

% of people on diabetes registers with a collaborative care plan

2013/14

2012/13

June 2014 27

2011/12 2013/14 Change Annual

DMI 719.0 1294.8 80.1% 40.0%

Lambeth 418.0 829.2 98.4% 49.2%


Southwark 266.0 465.6 75.0% 25.0%

0

200

400

600

800

1000

1200

1400

2010/11 2011/12 2012/13 2013/14

An

nu

al A

tte

nd

ance

s

Attendances at structured education

DMI Lambeth Southwark

Attendances at structured education: the number of patients attending structured education, note for Lambeth this includes DESMOND and alternative courses.

Source: Local DMI data

No comparator

Systematically offer people education on diagnosis

June 2014 28

Support primary care to deliver best practice

June 2014 29

60%

65%

70%

75%

80%

2010/11 2011/12 2012/13 2013/14Pe

rce

nta

ge o

f p

eo

ple

on

dia

bet

es

regi

ste

r (a

ged

17

+)

HbA1c ≤ 64mmol/mol

DMI ONS group Blue group London England

ONS group: Brent, City &

Hackney, Haringey, Lewisham, Newham

Blue group: Barnet, Camden,

Croydon, Enfield, Greenwich, Hammersmith & Fulham, Haringey, Hillingdon, Islington, Kensington & Chelsea, Kingston, Lewisham, Richmond, Sutton & Merton, Waltham Forest, Wandsworth, Westminster

Source: National data – QOF


DMI 67.3% 67.8% 0.7% 0.3%

ONS group 67.0% 65.1% -2.8% -1.4%

Blue group 68.9% 66.0% -4.1% -2.1%

London 68.5% 66.3% -3.2% -1.6%

England 70.5% 68.5% -2.8% -1.4%

Better glucose control for over 5,500 people

June 2014 30

Healthy blood pressure control for over 6000

people

60%

65%

70%

75%

80%

2010/11 2011/12 2012/13 2013/14Pe

rce

nta

ge o

f p

eo

ple

on

dia

bet

es

regi

ste

r (a

ged

17

+)

Blood pressure ≤ 140/80

DMI ONS group Blue group London EnglandONS group: Brent, City &

Hackney, Haringey, Lewisham, Newham

Blue group: Barnet, Camden,

Croydon, Enfield, Greenwich, Hammersmith & Fulham, Haringey, Hillingdon, Islington, Kensington & Chelsea, Kingston, Lewisham, Richmond, Sutton & Merton, Waltham Forest, Wandsworth, Westminster

Source: National data – QOF


DMI 61.8% 66.4% 7.5% 7.5%

ONS group 64.6% 66.2% 2.4% 2.4%

Blue group 63.1% 65.3% 3.6% 3.6%

London 64.0% 66.3% 3.6% 3.6%

England 65.2% 67.2% 3.0% 3.0%

June 2014 31

• 3,951 more people with diabetes received all 9 care processes in 2013/14

• Greatest improvements in ACR, foot checks and smoking status

Big improvements in people receiving all

Nine Care Processes in primary care

31.53%

45.50%

34%

47.71%

0% 10% 20% 30% 40% 50% 60%

2012/13

2013/14

Percentage of diabetes register receiving all 9 care processes

Southwark Lambeth

June 2014 32

Learnings

• Measurement tells the story of change and helps the

“flame shine bright”- macro, meso and micro levels

• Creates shared purpose and ambition, and a route map

• System measures shine light into the shadows and

across our “borders”

• User led measures truly test the process or experience

• Draw on multiple expertise and methodology

• Accept the data isn’t perfect



6 May 2015

Sustainability – establishing and maintaining the right relationships

Dr Nigel Hewett Medical Director Pathway

Hewett et al. A general practitioner and nurse led

approach to improving hospital care for homeless people

BMJ 2012;345:e5999

Establishing Relationships

• Needs assessment – gathered data and opinions from all stakeholders in hospitals and community, especially service users

• Steering group for needs assessment became steering group for the project – key clinical managers from the 3 Trusts, KHP and Lambeth CCG (commissioners)

Maintaining Relationships

• Continuous process of progress reports, launch events, annual reports

• Data and outcomes presented in a way which chimes with current drivers for the particular audience

Homeless people attend A&E 5 times as much, are admitted 3 times as often, and stay 3 times as long as the general public. Overall they cost 8 times as much.1

The average age of death for homeless people is just 47 years.2

Why target homeless people?

• Marmot review –‘proportionate universalism’

• Public Health Outcomes Framework

• Health and Social Care Act 2012

and the policy reasons…

• Tri-morbidity• Lack of follow-up care

Lack of local connection and/or lack of appropriate accommodation options

Chaos in the client group

Why the poor outcomes….?

The ‘Pathway’ approach

Bed days reduced by 30%... and

a better patient experience

How was this achieved?

• Maximising the benefit of admissions

• Expert and sensitive support team with specific skill sets

• Team fully linked in to homeless community services

• Delayed discharges

Homeless attendance data 2011

A&E

attendances

Hospital

admissions

Cost

GSTT 4923 1379 £5,623,810

KCH 718 240 £947,289

SLAM 148 £2,670,553

A pilot service involving 13 staff

•Multi-agency…

A new pathway for homeless patients

• Attending St Thomas’,Guy’s or King’s

Homeless person

• GSTT base: GP 0.4 wte; RN 2 wte; OT 1wte; HSW 3 wte; Admin 1wte

• KCH base: GP 0.4 wte; MHP 1 wte; SW 0.4wte; HSW 1 wte

KHP Pathway

Homeless Team

• Practical assistance

• Health review

• Housing

• Reconnections

• Frequent attender work

• Safeguarding

Integrated,

multi-professional assistance

•Outreach teams

•Day centres

•Homeless health teams

•GP practices

Community support

• Peer advocate support with physical health appointments and GP registration

Groundswell

What do we do?

• Practical assistance

• Comprehensive health reviews

• Linking in with community services

• Help to find housing

• Reconnection work

• Frequent attender casework

• Safeguarding of vulnerable adults

• Tap-dancing, juggling, stand-up…

Maintaining Relationships

• “Integration”, “KHP”, “Mental and Physical Health”, “Health Inequalities”, “Value”, “Efficiency” A&E frequent attenders etc etc.

• Encourage ownership by partners – share the benefits – look at this fabulous thing you have done!

Data at 4 weeksGSTT Kings

No of referrals 116 (109 people)

40(39 people)

% on CHAIN 75% 22%

Key referral routes 39% from A&E

22 wards

Community

25% from A&E

19 wards

Community

Data at 4 weeks

GSTT Kings

% seen / casework

undertaken

93% 82%

% improved

housing status at

discharge

28.5% 32.5%

Reconnections 8 1

Feedback

questionnaires

19 returned –

16 ‘excellent’,

3 ‘good’

1 returned –

‘excellent’

Borough links on dischargeGSTT Kings

Westminster 18.9% -

Lambeth 15.8% 18.1%

Southwark 13.1% 27.5%

Lewisham 3.7% 9%

Other London 14.9% 12.1%

Outside London 19.6% -

Unknown 14% 33.3%

Case Studies – tell the stories

Thank you



6 May 2015