London Primary Care Quality Academy April 2019
The Dilemma What the NHS Experiences What the NHS needs • Adaptive capability • Increasing complexity • Creative solutions • Desire to create control • New capacity and and simple solutions resources • The need for certainty in • Experimentation an uncertain environment Requiring leadership through relational culture Based on experience in leading in transactional cultures
Networks “Networks have become the predominant organizational form of every domain of human activity” Castells (2011) “Networks are cooperative structures where an interconnected group of 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
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
Typology of Networks Delivery/ • Collaboration and Coordination Development • Boundary Spanner • Hub and Spoke Networks Learning & • Shared and New Knowledge Support • Distributed Leadership • Passion and Commitment Networks Agency/ • Amplification and Advocacy Advocacy • Dynamic Leadership • Democratic engagement Networks
ROBUST GENERAL PRACTICE
Critical Themes in High Performing Systems Adapted from Baker & Denis 2011 Leadership & Strategy Organising Design Improvement Capabilities Quality and systemic Robust primary care teams at Proactive approach to building improvement as a core strategy the centre of the delivery skills for quality improvement system across the system Leadership activities embrace More effective integration of Information as a platform for common goals and align activities care that promotes seamless guiding improvement throughout the system / network transitions of care Clinical leadership is supported by Promoting professional cultures Effective learning strategies and professional management that support teamwork, methods to test and scale up continuous improvement and across the system patient engagement Shared decision-making with Providing an enabling Engaging patients in the their patients and families environment buffering short- care, and in the design of care term factors that undermine success
What is The Work of General Practice? Variation between GPS from 40% of my appts are appropriate to 90% are appropriate
Acting as a Prevention witness and and treatment supporting of disease meaning Biomedical Healing The messy issues that require intimate Caring relational about and continuity feeling with - Caring Biographical empathy Pratt 2009
Primary Care Quality Academy Team Based Approaches NEW WAYS OF WORKING HOW WE WORK NOW Community Assets Patient Groupings and Tailored Services F2F GP/Nurse Better relationships with to Patient wider services F2F GP/Nurse to Patient NOW FUTURE MANAGING DEMAND MEETING DEMAND FOUNDATIONS Creating the Practice Signposting Partnering Data Approach and with foundations (reducing organising Community variation of clinical approach)
Purposeful (Practice) Purposeful Transactional (PCN) (Practice)
The Bedrock - Resourceful Communities • Connecting people / creating meaningful activities / generating self-esteem
Community asset-based What Economies of scale partnerships at meaningful population (up to 14K) to reduce demand. Practice/ Scale for Town/ Parish Council. What Collaborating on back office, Business Intelligence and some service delivery, and Work? Learning Collaboratives - some skills sharing (at 30K Borough size (2-350K) -50K) – Primary Care Network/ Locality Working at scale Complex Needs to stop Securing quality in Care tipping into unstable - MDT Homes (numbers of care to support (Locality/ homes – all registered with Constituency size/ Primary one practice) – can be a PC Health Care Teams)) Network
ECONOMIES OF SCALE/ WORKFORCE REDESIGN
We illustrate GPs own assessment of appropriateness of appointments Question to GPs: Should this patient be here today? Answer from GPs: 40% of the time ‘no’ 100% OTHER 90% NON-CLINICAL problem In a practice 80% 30-50% of REFERRAL/PRESCR.FROM HOSPITAL appointmen 70% TEST RESULTS (no concern) ts are seen 60% as SERVICES OUTSIDE PRACTICE inappropriat 50% Necessary/ appropriate SICK NOTE e or 40% SELF-CARE / SELF-HELP GROUP moveable. 30% PHARMACIST could handle 20% OTHER STAFF could handle 10% NECESSARY appointment 0% 17
Nick Downham Economies of Scale Working at Scale Driven by classic economic and Driven by a support, service or industrial thinking from the 1700s, innovation need that can only be 1800s and early 1900s. achieved at a certain scale. What is it driven by? Four driving principles: • To support the maintenance of a • Division of Labour (Adam Smith) certain technical expertise. • Functional Specialism (Max Weber • To provide depth and quality of and Adam Smith) collaboration network. • The role of Market (Adam Smith • To reflect natural sizes of and many more) communities. • Unit costing • To support team based approaches**
Nick Downham Economies of Scale Working at Scale • Specialism of roles and teams. • Specialist centres where there is a a genuine need for deep specialism from a technical • Introduction of greater number of perspective. For example specialist heart different, and often more specialised centres or Neighbourhood hubs for roles. Spirometry interpretation (not taking). • Greater emphasis and specification of What does it look like in practice? • Genuine multi-disciplinary team based tasks and roles (often to allow for approaches (for example Intermountain’s greater division of labour). Management primary care MH team based approach). of services around labeled needs*. • Autonomous generalist team (neighbourhood) • Consolidation of organisations (often to based approaches such as the Nuka system or Buurtzorg approach. allow for greater volumes of functional • More generalist competencies. specialism) • Driven by contextual (social determinants) • Outsourcing of functions. needs of patients as well as the health needs. • Bulk buying • Systems that seek to meet need at the earliest • Batching of work possible instance, rather than label and • Short contracting cycles handoff. • Introduction of greater numbers of • Community networks meeting much of the assessments and gateways. population need rather than the formal services. • Concentration on intervention (unit / • Understanding of end to end cost rather than point / episode) costs. intervention (unit or point cost).
• Greater number of handoffs in • Reduction in failure demand and order to get ‘work done’. Creating thus overall system cost. failure demand (more work – • Simpler systems (less requirement typically felt elsewhere). for costly management • Individuals and departments infrastructure). concentrate on getting their bit • Less system fragmentation and thus What impact does it have? (their specialism) done, and then greater communication. handoff. • Needs (H or S) driven care . • Work is bounded by the • Empowered staff. specification . • Greater view of the whole . • Staff get de-motivated by only doing • Aligned priorities. a limited number of tasks. • Stronger networks. • It is almost impossible to be • Stronger communities. flexible. • Responsibility for the whole is lost. • Individual interaction costs go down , overall costs typically go up. • We lose the ability to take into account a patient’s context. • Supply driven care. • Conflicting priorities. *Source: Richard Davis / John Seddon (Vanguard) ** Team based approaches are not the same as broadening skill mix – which is generally a form of division of labour)
In summary: Economies of Scale thinking comes from study around VERY simple and bounded processes. For example pin making. • The very real risk is that the end result of applying this thinking to purposeful and relational services is that we create failure demand. By either not meeting or delaying the meeting of need. We shift cost to elsewhere or later. Working at scale is about enabling a technical expertise or team, network or community innovation that genuinely cannot be achieved without a certain scale. • They speed up the meeting of need, rather than delay or possibly not meet it.
WORKING AT SCALE
Where to start • Needs First • Data enabled for Quality • Primary Care is the starting place • Telehealth to support • Secure best health • Manage complexity through MDT • Integrated record • Long term outcomes based contracts • Effective peer leadership
Transactional Prevention Urgent Care Housekeeping E-record flags Minor Routine diagnostics Acute and Diagnose Paperwork Acute and escalate Payment services
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