U l hi D iUnleashing DynamismA Case Study:The Trafford Story of

Integrated Care

Presented by:Samantha Nicol

Integrated Care System Programme DirectorDr Nigel Guest

General PractitionerNuffield Summit March 2011

Unleashing DynamismUnleashing Dynamism

• Intensity• Enthusiasm } qualities that enable people

to get things done• Motivation

• Work systems• Language } dimensions of organisational dynamism• Interpersonal stylep y• Modes of thinking• Mindsets

• incentives – leadership – information - policy

Let’s see what you think?Let s see what you think?

• For just 5 minutes discuss what you thinkFor just 5 minutes discuss what you think unleashes dynamism in the programmes, strategies and projects you are currently working on

• Feedback – create a list

In the beginningIn the beginning……

Then there wasThen there was……

50 years of change50 years of change FHSA

C it T t Community Trust Foundation Trust Hospital Trust Area District Strategic Health AuthorityArea District Strategic Health Authority

And so we arrive at 2008 – intolerable diticondition

What have been your intolerable diticonditions

• For just a couple of minutes think what yourFor just a couple of minutes think what your intolerable conditions have been that have prompted you to look to unleash dynamism

• Feedback – common themes?

And one manAnd one man

And another manAnd another man

Intermountain HealthcareIntermountain Healthcare Utah 1975Utah 1975Intermountain Healthcare Intermountain Healthcare Utah, 1975Utah, 1975

Perceived strengths of IntermountainPerceived strengths of Intermountain Perceived strengths of IntermountainPerceived strengths of Intermountain Pioneering use of electronic medical records: Pioneering use of electronic medical records: ‘‘datadata--driven approachdriven approach’’ Measure, track and thereby improve clinical outcomesMeasure, track and thereby improve clinical outcomes EvidenceEvidence--based medical care guidelinesbased medical care guidelines Preventative medicinePreventative medicine RiskRisk--stratification of the patient populationstratification of the patient populationp p pp p p Balance between needs of the community and available resourcesBalance between needs of the community and available resources

NonNon profit health care deliveryprofit health care delivery NonNon--profit health care deliveryprofit health care delivery

IntermountainIntermountain’’s integrated system:s integrated system:f tl it d b th Ob d i i t ti th if tl it d b th Ob d i i t ti th i l f hi hl f hi h–– frequently cited by the Obama administration as the prime exampfrequently cited by the Obama administration as the prime example of a highle of a high--performing performing organisationorganisation that reduces healthcare coststhat reduces healthcare costs

And then a few more menAnd then a few more men

It’s also aboutIt s also about

Unleashing dynamism through VISIONARY LEADERSHIPVISIONARY LEADERSHIP

• That is:– Vision– Environment– Relationships– Power– PerformancePerformance– Self– Communication– System and processes

Unleashing Dynamism through RELATIONSHIPSRELATIONSHIPS

• Manipulating the environment through team spiritp g g p• Removing hierarchy, value individuals in their

own right• Emphasis on the team finding the solution• Focus on points of connection building trust and

trapport • Giving power to others – asking people what

they think coaching conversationsthey think, coaching conversations

Then lot’s more men and a few womenThen lot s more men and a few women

PrinciplesPrinciples

• Clinical Congress 2008Clinical Congress 2008

• PrinciplesPrinciples

• Scope of design• Scope of design

Trafford’s principles of integrated careTrafford s principles of integrated care• Principle one: General Practice should be ‘locus of integration• Principle Two: Consultant opinion is an essential component of

effective integrated serviceseffective integrated services• Principle Three: The delivery of integrated services will primarily

rest on extended role nursing and allied health professionals• Principle Four: Integrated services will be enhanced by the p g y

involvement of social care• Principle Five: The voluntary sector and carers need a strong voice

in the design and delivery of services• Principle Six: Future integrated services would bring together the• Principle Six: Future integrated services would bring together the

full range of primary care• Principle Seven: Unscheduled care should be simple to access

and fully integrated• Principle Eight: Where benefits can be derived from co-operation

between integrated care services and conventional acute hospital services we will secure them

Create the Vision (1)C eate t e s o ( )

The presentThe present

THT/UHST/CMMCPCT

Community Non PbR Inpatientservices Non-PbR

services

Outpatients

Inpatient, daycase, specialist

GP1 GP3 GPn

and diagnostics(Independent)

GP4GP2 … and we have persistent issues of poor integration, resilience and perhaps quality… is there a structural problem?

Systematic exploration of SPMS/ alternative t d d i id (2)extended primary care provider (2)

The future?The future?

THT/UHST/CMMCPCT SPMS practice: GPs and consultants as partners

Community Non PbR Inpatientservices Non-PbR

services

Outpatients

Inpatient, daycase, specialist

Integrated Care Recordand

diagnostics

GP1 GP3 GPn

(Independent)

Integrated Care Record

GP4GP2Or FT for THT

Systematic exploration of SPMS/ alternative t d d i id (1)extended primary care provider (1)

The present

Unleashing Dynamism through FOUNDATIONSFOUNDATIONS

• In order to support the unleashing of dynamism you haveIn order to support the unleashing of dynamism you have to have rules of engagement and foundations on which you can build on

• People have to know what they are getting involved in• People have to know what they are getting involved in and what direction they are going in

• This helps them to know what resources they can offer d h t th h t hand what power they have to exchange

• The vision inspired and created passion and enthusiasm, its development involved people from the startp p p

But that is not enoughBut that is not enough…• Between 2008 and 2010 there was a series of

b i b itt d t th St t ibusiness cases, submitted to the Strategic Health Authority and PCT for funding to support these leaders and the relationships to developthese leaders and the relationships to develop the vision and implement the principles across Trafford to develop an integrated care system p g yand an integrated care organisation through which integrated services could be delivered.

It is probably NOT about permission d f diand funding

• Two business cases, very detailed and developed with , y pthe help of external consultancy did not achieve their required outcomesAlth h th did i th b t th i i• Although they did raise the awareness about the vision and the potential of that vision to achieve dramatic change to the way services are provided and their cost

• But their proposals were probably just too big and risky

You have done all that…..You have done all that…..

• What else is there??What else is there??

Unleashing Dynamism through TESTING ‘P f f C t’TESTING - ‘Proof of Concept’

• What they did do however, was achieve a £2mWhat they did do however, was achieve a £2m investment and a year to develop the infrastructure necessary to deliver the vision

• It came back to – Leadership– Relationships– Framework

In ActionIn Action

• The following slides set out a series of case gstudies taken from Trafford’s Integrated Care System Programme that has now been running for nearly one yearfor nearly one year

• Highlighting the elements of unleashed dynamism across multi professional groupsdynamism across multi professional groups, multi organisations and during one of the most turbulent times in the NHS in 60 years

Context

• Put in programme p gstructure

Then CameA W !!A Woman!!

Unleashing Dynamism through OG GPROGRAMME MANAGEMENT

• As a vehicle for implementing strategy and for bringing about corporate renewal as alternative organising structure

• Programme as an emergent phenomenon, conscious of and responsive to external change and shifting strategic goals

• Framework/structure therefore atemporal or with indeterminate time horizons

• Vehicle for enhancing corporate vitality concerned with nurturing of individual and organisation-wide capabilities as well as the efficient d l t fdeployment of resources

• Intimately bound up with and determined by context rather than governed by a common set of transferable principles and processes.

• Not a scaled up version of project management • Adaptive not prescriptive

Unleashing Dynamism through PROGRAMME MANAGEMENTPROGRAMME MANAGEMENT

• Leadership at all levels, skilled individuals with clearly defined authority, accountability and responsibility and programme governance aligned to sources ofaccountability and responsibility and programme governance aligned to sources of influence

• Benefits management – identification, quantification, owners and tracking• Stakeholder management and communications – understanding stakeholders

interests and impact of the programme, engagement of themg g g• Risk management and issue resolution – managing risk at an acceptable level• Planning and control – prioritisation of projects and grouping of projects linked to

benefits realisation• Business case management – value management of benefits, costs, timescales and

risksrisks• Quality management – configuration management, change control on documentation,

quality assurance and review of outputs to ensure they are ‘fit for purpose’

Unleashing Dynamism through PROGRAMME MANAGEMENT

• Engaging people as change agents

PROGRAMME MANAGEMENTEngaging people as change agents

• Realistic about the effort of change• Link between behaviour and outcomesLink between behaviour and outcomes• Priority to systems that provide touch points with

individuals and teamsindividuals and teams• Used to provide space for the conversations• Seeing culture as embedded in actions• Seeing culture as embedded in actions

Clinical PanelProject Manager’s

• Louise Rogerson – End of Life• Andrew Giles – Respiratoryp y• Brooks Kenny – Diabetes• Guy Hamilton – Data Sharing / Information• Ric Taylor – Mental Health• Tim Weedall – ENT• Jason Hughes – Unscheduled Care

Andrew GilesRespiratory Project ManagerRespiratory Project Manager

Gail MannICS Programme ManagerICS Programme Manager

Diabetes Clinical PanelDiabetes Clinical Panel

• Put in picture of PanelPut in picture of Panel

Unleashing Dynamism through CLINICAL PANELSCLINICAL PANELS

• A safe shared space to build relationships that are about li i l t b t i ticlinical care not about organisations

• Chaired by a primary and secondary care clinician• A good mix of opinions, but essentially commonly shared g p y y

and owned values• Patients and carers• Clear strategic outcomes – focussing on quality ofClear strategic outcomes focussing on quality of

clinical care and clinical outcomes measuring improvement

• Time

Unleashing Dynamism through CLINICAL PANELSCLINICAL PANELS

• Management supportg pp• Information/data – about their current patients

and clinical practice• Shared aims• Small steps

• [Any chance we could do this like a jigsaw coming together with previous slide and make itcoming together with previous slide and make it one slide?]

Unleashing Dynamism through SHARED INFORMATIONIllustration 1 – risk stratification (diabetes)Illustration 1 risk stratification (diabetes)

Band1 Band2 Band3 Band4 Band5BiochemicalHbA1c <7 7‐9 >9 don't knowHbA1c date <13months >13months don't knowHbA1c date <13 months >13months don t knowSystolic Blood pressure <120 120‐140 >140 don't knowDiastolic Blod pressure <70 70‐90 >90 don't knowSerum Cholesterol <5 >5 don't knowserum Creatinine (kidney) <120 120‐200 >200 don't knowMicroalbinuria <3 >3 don't know

Microvascular comorbitiesChronic Kidney Disease 1 2 3 4 5Diabetic Neuropathy yes No don't knowDiabetic Neuropathy yes No don t knowRetinopathy yes No don't know

Macrovascular comorbiditiesMI (ACS/NSTEMI/STEMI/ANGINA) yes noCVA (TIA/RIND/CVA) yes noPVD yes no

OtherAge 18‐44 45‐64 65+Age 18 44 45 64 65+Hospital admissions in last 12m 1 2 or more

Unleashing Dynamism through SHARED INFORMATION

Ill t ti 2 i k t tifi ti (di b t )Band1 Band2 Band3 Band4 Band5

BiochemicalHbA1c <7 7‐9 >9 don't know

Illustration 2 – risk stratification (diabetes)

HbA1c date <13 months >13months don't knowSystolic Blood pressure <120 120‐140 >140 don't knowDiastolic Blod pressure <70 70‐90 >90 don't knowSerum Cholesterol <5 >5 don't knowserum Creatinine (kidney) <120 120‐200 >200 don't knowMicroalbinuria <3 >3 don't knowMicroalbinuria 3 3 don t know

Microvascular comorbitiesChronic Kidney Disease 1 2 3 4 5Diabetic Neuropathy yes No don't knowRetinopathy yes No don't know

Risk Category

Macrovascular comorbiditiesMI (ACS/NSTEMI/STEMI/ANGINA) yes noCVA (TIA/RIND/CVA) yes noPVD yes no

Category 1

OtherAge 18‐44 45‐64 65+Hospital admissions in last 12m 1 2 or more

Note: For illustration onlyy

Advanced Training ProgrammeAdvanced Training Programme

Unleashing Dynamism through COMMUNICATIONCOMMUNICATION

In SummaryIt is all about… It is not all about…..

A burning platform or an intolerable condition

Visionary Leadership at all levels Seeking permissionVisionary Leadership at all levels Seeking permission

Relationships – cross organisational and professional boundaries Funding

Foundations – vision, values Organisations

Programme Management – providing a framework to support creativity and innovation while ensuring shared learning, transparency of benefits and accountability

Bricks and Mortar

Command and control

UNSCHEDULED CAREUNSCHEDULED CARE

I leave you with this thoughtI leave you with this thought….

• Matthew chapter 4 verses 12 -23p– A fisher of men a leader calling to his followers caught through

teaching and persuasion– Together grasp the sense of what is needed to be done– Build on what has been done well in the past– Called to serve

• Vision, energy, enthusiasm– Hearts turned by

• Hands willing to get dirty• Working together to deliver a vision.