BRINGING AN EVIDENCE BASE TO DECISION- MAKING COMPLEX ENVIRONMENTS. - - PDF document

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BRINGING AN EVIDENCE BASE TO DECISION- MAKING COMPLEX ENVIRONMENTS.

North West London Research Symposium Prof Becky Malby

CHALLENGING PREVAILING ASSUMPTIONS

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What you see determines what you do

Many practices hold numerous hypotheses that shape their current work

• Demand is rising
• We are just meeting it but can’t carry on – we

don’t turn people away

• We don’t have enough capacity and we need

more staff/ money

• Frequent attenders all have more than one

chronic disease

• Secondary care shifts the burden onto us
• Social care is failing

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The big picture of demand vs. capacity is optimistic

• While typically 15% - 20% of appointment requests can’t be meet at reception in a practice
• This is far less than the 40% of GP appointments that are seen as inappropriate – unnecessary,

avoidable or potentially moveable within the practice

* Over 10,000 contacts / appointments ** Not including missed calls

Unmet demand* Inappropriate appointments is far less than Reception contacts GP appointments

Academies combined*

 Appointment booked No appt possible  Appropriate appt

85% Yes 15% No 60% appropriate 40% Inapprop.

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GP views: There is significant variation on what constitutes a GP appointment

Within practices….

Variation between practices from ‘ 80% of our appts are inappropriate’ to ‘less than 50% of

• ur apps are

appropriate’ Variation between GPS from 40% of my appts are appropriate to 90% are

Across practices….

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Super Attenders go to GP Surgeries because they have what sort of problems?

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Identifier Age Gender GP appts Nurse appts Attender category GP #1 % GP #2 % QOF registers QOFs 1 64 yrs Female 46 5 Super attender 30% 20% 1 CHD, 2 49 yrs Female 39 2 Super attender 62% 15% 1

• besity,

3 51 yrs Female 35 6 Super attender 86% 14% 3 cancer,mental_health,obesity, 4 97 yrs Female 35 1 Super attender 54% 46% 1 atfib, 5 52 yrs Male 34 4 Super attender 38% 26% 1 depression, 6 23 yrs Male 33 4 Super attender 67% 12% 1 learning_disability, 7 47 yrs Female 33 Super attender 70% 15% 8 64 yrs Female 33 4 Super attender 33% 27% 2 CVD,hypertension, 9 72 yrs Female 32 7 Super attender 56% 16% 1 stroke_tia, 10 37 yrs Female 30 9 Super attender 27% 23% 1 asthma, 11 62 yrs Male 29 5 Super attender 28% 28% 3 asthma,CVD,hypertension, 12 63 yrs Female 28 2 Super attender 46% 29% 1 diabetes, 13 48wks Male 26 3 Super attender 38% 23% 14 61 yrs Male 26 1 Super attender 23% 23% 3 asthma,cancer,depression, 15 46 yrs Female 26 Super attender 73% 27% 2 depression,mental_health, 16 56 yrs Female 26 2 Super attender 54% 19% 17 96 yrs Female 26 2 Super attender 65% 27% 2 CKD,dementia, 18 48 yrs Male 24 2 biweekly 46% 17% 1 depression,

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Frequent attender review (top 100)

Life situation: Over half are known to be in a struggling or chaotic life style

People who attend frequently are a product of the General Practice’s behaviour not the population’s health

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TAKING AN EVIDENCE BASED APPROACH

A&E is Overburdened (Breaches ) Because

A Demand is rising – more people are coming to A&E B Primary Care is Failing C There are no beds in the hospital so there is backlog D A&E is doing more tests and interventions so the workload is changing E We don’t have enough clinicians in A&E

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The evidence?

A&E breaches are related to

• increasing acuity/ complexity,
• increased length of stay,
• staffing and facilities out of pace with the

changes in need in A&E,

• increase in case management within A&E,

not as the dominant narrative suggests, as a result

• f increased numbers and poor primary care

Wyatt, S. (2019) Waiting Times and Attendance Durations at English Accident and Emergency Departments. The Strategy Unit

POWER OF NETWORKS

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Do Well Do Well

Mechanistic Mechanistic Control Control

Do Better Do Better

Participative Participative Improvement Improvement

Do Better Things Do Better Things

Relational Relational Coproduction Coproduction

adapted from Anderson-Wallace, Blantern and Boydell,2000-2007

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6 months 6 months 6 months 6 months later admitted to Mental Health Hospital 6 months

2 years of 2.5 recorded

And the GP said…

“If all the teams this individual encountered in the past 2

years actually worked together (not just lip service to integration) e.g. sat in the same place, discussed cases together, she would have found herself in the right place having the right care for her much sooner

”

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Managing Complex Needs

Mildly & Moderately Complex level 1 Mildly & Moderately Complex level 1

• Practice &

Community High Complexity level 2 High Complexity level 2

• PCN

High Complexity (including specialist care) level 3 High Complexity (including specialist care) level 3

• ICS

Networks

“Networks have become the predominant organizational form of every domain of human activity” Castells (2011) “Networks are cooperative structures where an interconnected group

• f individuals, coalesce around a shared purpose and where members

contribute as peers on the basis of reciprocity and exchange (in turn based on trust, respect, and mutuality).” Malby & Anderson-Wallace (2016)

Useful For

• Generating creative and innovative solutions
• Rapid learning and development
• Amplifying the effectiveness of individual members

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Networks Work When:

• There is clear shared purpose and identity
• They are creative and innovative
• They meet member needs
• They are supported by adapted leadership
• They have strong relationships and ties
• They generate helpful outputs

CLEAR PURPOSE

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PCN Range of Purposes/ Intent (Actual Intent)

a) Learning and innovation b) Delivering complex care/ integrated care (for some as part of the ICS) together c) Support communities to help themselves – increasing community assets d) Get upstream into prevention by collaborating with schools/ nurseries/ families e) Act as an integrator – connecting and enabling partners

Network Approach: Working at Scale

PCN Range of Purposes/ Intent (Actual Intent)

a) Alleviate GP pressures (new staff), improve workload and therefore improve workforce job satisfaction b) To get the income (practices won’t survive without the NCDES) and scalable investment c) Deliver extended hours d) Sort out failing / struggling practices

Transactional Approach: Economies of Scale

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Typology of Networks

• Collaboration and Coordination
• Boundary Spanner
• Hub and Spoke

Delivery/ Development Networks Delivery/ Development Networks

• Shared and New Knowledge
• Distributed Leadership
• Passion and Commitment

Learning & Support Networks Learning & Support Networks

• Amplification and Advocacy
• Dynamic Leadership
• Democratic engagement

Agency/ Advocacy Networks Agency/ Advocacy Networks

Delivery Networks Learning Networks Agency Networks

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Learning Networks Communities of Practice

“Communities of practice are groups

• f people who share a concern or a

passion for something they do and learn how to do it better as they interact regularly.” Wenger-Trayner 2015 Critically therefore CoP member instigates / joins a CoP because:

• They care about the domain (of

practice)

• They have shared competence

and practice

• They want to learn together how

to develop their practice (at a detailed competence level). https://beckymalby.wordpress.com/2017/12/05/facilit ating-communities-of-practice/

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LSBU Primary Care Quality Academy

• Advocate for improvement and

innovation in Primary Care

• Provide local solutions and

programmes where there is a gap

• Coach and supervise local newly

developed teams in these skills and approaches.

• Facilitate strategic development in

these areas.

• Host pan-London communities of

practice

• Catalyse the development of data

scientists, data literacy for improvement and innovation in professionals and citizens.

Networks Fail Because Of:

• Fails to reach common understanding across members of

purpose and direction

• Over-management cementing relationships and structures that

need to be dynamic and evolving & Institutionalisation

• Over expectation of network member’s willingness or ability to

collaborate which damages creativity of the parts

• Predicating some members over others,
• Constraining network member’s independence,
• Not recognising when leadership needs to change / rotate
• Lack of impact in terms of network member’s purpose.

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The Old World Bites Back –what to watch out for

• 1. Culture eats strategy
• 2. Tendency to turn wicked problems into tame – segmenting and making

project groups who find they cant solve the problem and the issue goes round and round.

• 3. Tendency to structure as a hierarchy/ beurocracy rather than a

network – with:

– Lack of clarity on accountability in partnerships/ collaboratives/ networks – unclear meeting purpose and function. Longer and longer agendas. – Lack of clarity on what change process is required/ at what level – defaulting to project management. – Lack of clarity on role at system level/ lack of clarity on delegated authority – leading to expanding workgroups

• 4. When the going gets tough NHS reverts to performance management,

Local Government reverts to local differences.

@BeckyMalby

www.beckymalby.wordpress.com r.malby@lsbu.ac.uk www.source4networks.org.uk

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