How Ealing Health Networks can contribute to efficient and quality healthcare

Key messages

Clinical Commissioning Groups should develop clusters of general practices to contribute to the infrastructure required to build a NHS based on productive inter-organisational relationships capable of improving quality and containing costs.

Why this matters to me

Integration of the whole healthcare sector (primary, community, mental health services and secondary) and social care services are of paramount importance to Ealing Clinical Commissioning Group. As a clinical commissioner, I see Health Networks as the vital platform to allow the integrated care mosaic to develop and then deliver improved and optimised health and social care journeys for patients now and in the future in Ealing.

Abstract

We describe how the formation of Health Networks in Ealing leads to improved outcomes for patients by the coordination of the care they receive by health and social care professionals.

Introduction

The Integrated Care Pilot (ICP) shows that practitioners of different disciplines enjoy coming together at monthly workshops to make care plans for patients with complex health and social care needs and to exchange ideas about how to improve health and social care locally in their network and within their borough. Overall, it reduces unscheduled hospital attendances because it provides a mechanism to anticipate problems and create low-cost solutions at a local level.¹

Care plans are valuable because they unearth problems at an early stage and put in place plans and interventions to anticipate and prevent later problems. But the workshops have an equally valuable outcome of building trusted relationships across organisational and disciplinary boundaries. Trust is the secret ingredient of integrated care – it makes it easier to ask for advice and work with others to devise innovations. Costly referrals can often be replaced by cheap telephone calls, and clever ways to improve quality. It provides a richer professional experience.

One important ingredient of trust-building is the size of the area in which activity happens. A population of 50 000 – 10–20 general practices – is small enough to feel you belong and large enough to have political clout. It allows a sense of community to develop. Recognising this potential, Ealing (population 390 000) has established seven geographic areas, termed Health Networks, to encourage collaborative working.

Here, we discuss ways that Ealing and other Clinical Commissioning Groups (CCGs) could develop Health Networks that systematically build healthcare systems based on productive interorganisational relationships.

An old truth about relationship-based systems

It is not surprising that the ICP workshops build productive relationships between those who take part. It is well known that this kind of multidisciplinary, co-creative activity nurtures teamworking.² It stimulates critical thinking, mutual appreciation and trust. When a shared experience is positive and deep, it has a long-lasting beneficial effect on working relationships. When it is negative and superficial the reverse is true. This is why shared experiences that result in mutually agreeable positive change are the goal of all relationship-building initiatives – community development, family therapy and relationship counselling, for example.

What is less obvious is the beneficial effect on those in a community who do not take part. Cultural change happens in the shadow systems. Chats in corridors and clubs, throw-away remarks at tea breaks, articles in newspapers, recommendations from friends – these also build relationships and quietly change the way people think, with or without direct experience.

CCGs can use this old truth that relationship-building lies behind both quality and culture change by creating an infrastructure of support for innovations that provides multiple opportunities to hear about and take part in multidisciplinary activities to improve care.

Need for combined vertical and horizontal integration

CCGs took over the role of Primary Care Trusts in April 2013. As with all previous authorities, they will encounter tension between ‘top down’ implementation of policy and ‘bottom up’ development. The former is fast, but can disempower. The latter empowers local people as champions of change (because they co-created it), but is slower to achieve.

It is more complicated because ‘top down’ and ‘bottom up’ approaches use different methods that have different advantages and disadvantages. ‘Top down’ models come from other places and have the weakness of integrating poorly with the local system, inevitably emphasising ‘vertical integration’. ‘Bottom up’ models work with local people, inevitably emphasising ‘horizontal integration’, and have the weakness of ‘reinventing wheels’.

Effective healthcare combines ‘top down’ and ‘bottom up’ approaches.³ However, models that systematically integrate both approaches are rare, as has been shown by Meads in his 31 country study of organisational innovation.⁴

Piloting combined horizontal and vertical integration in Southall

Working with international experts on integrated care, between 2009 and 2011, Ealing sponsored a model of comprehensive integration – the Southall Initiative for Integrated Care (SIIC). Multidisciplinary shared leadership teams facilitated annual cycles of interorganisational improvements, linked to the annual commissioning cycle.⁵ Connected learning events allowed broad groups of stakeholders to simultaneously explore new ideas and implement policy, cross-pollinating ideas and aligning their agendas for improvement.

Within one year, the initiative had engaged all 26 Southall general practices, community and hospital colleagues in four system-wide improvement projects. These projects (diabetes, dementia, mental health and health advocacy) became adopted by mainstream institutions. Within two years, the increased system-wide capacity to solve problems caused by the initiative was associated with reduced hospital episodes.⁵ This was achieved without new resources – outcomes resulted from using time differently to co-ordinate collaborative change.

Improving healthcare through productive relationships in Ealing

CCGs can apply learning from these initiatives to build a NHS based on productive interorganisational relationships. It requires a shared geographic space for different organisations to work together, as has been created by the ICP. It requires a range of other things (see a set of papers in LJPC Vol. 5, no. 1), including transformational leaders skilled at developing a local community for health improvements in these areas, routinely gathered data to evaluate progress, and an annual cycle of collective interorganisational reflection and co-ordinated improvements, to help diverse innovations to develop in synchrony. This approach sees organisations less as machines and more as brains⁶ – learning organisations.⁷ A ‘new localism’,⁸ will replace the ‘targets and markets’ approach of the new public management.⁸

To do this, Ealing and other CCGs need to:

• ensure that all practices in each Health Network collaborate for service improvements and delegated budgets, and take part in the ICP

• use the ICP workshops to oversee learning and innovation, as well as care plans, including an annual schedule of learning events to align multiple agendas

• develop admission-avoidance schemes (e.g. Integrated Care Ealing) as a signposting resource for practitioners and patients (to access carers, advocates, befrienders)

• work with university partners to streamline university resources through Health Networks to support leadership, innovation, research and student placements

• charge the Clinical Support Unit to provide monthly improvement and outcome measures to compare the global impact of multiple collaborative projects in each Health Network

• develop models of shared care for long-term conditions that allow most care to be undertaken locally by generalists with fast (real-time) access to specialists, and mechanisms to systematically build relationships between generalists and specialists, and between practitioners in healthcare, social care and mental health.

ETHICAL APPROVAL

This paper analyses the future application of previous service improvement projects and did not require research ethics committee approval. It has been approved by senior members of the Ealing Integrated Care Pilot, NHS Ealing and Ealing Clinical Commissioning Group.