Dudley Clinical Commissioning Group restructured services to ensure the patient was at the centre of networks of healthcare professionals, social workers and the voluntary sector. Paul Maubach and Simon Western explain how
Dudley Clinical Commissioning Group inherited a system of service provision that was structurally complex in which multiple providers often worked completely independently from each other.
‘Services managed and organised independently failed to consider that many patients would be users of several different services’
There were 47 GP practices; three NHS organisations providing multiple community services to different geographical groupings and access criteria; social services working to a different population structure from health services; and limited connections to the voluntary sector.
Frontline staff - let alone the public - found this web of service provision difficult to navigate. Furthermore, it hampered effective communication between professionals - each member of staff had to engage with many different colleagues for each patient.
- Mental health repatriation ensures patients are homeward bound
- Embed person centred care into mainstream health services
State of independence
Each organisation structured its services to ensure they were independently efficient, effective and operating in a way that made professional and economic sense for that service. For example, district nurses were working in 14 groups, but there were seven of the more intensive community “virtual wards”.
Because services were managed and organised independently, they failed to consider that many patients would be users of several different services. The organisational design may have been effective for an individual service, but it was not efficient for any individual patient or group of patients. It was service centric rather than patient centric.
The CCG’s first task was to redefine the premise on which the whole system of provision was structured so that all provision could become mutually patient centred.
Care was organised through rigid structures and layers, such as primary and secondary care, and divided by sectors: voluntary, local authority and health. However, we concluded that this rigid structure is insufficient for today’s networked society and for our population’s needs.
We analysed social and organisational change in other sectors, and applied the concept of “eco leadership” - whereby leadership is distributed throughout the system, rather than led by a top-down hierarchy.
This enables clinicians close to the patient to organise and make decisions with the individuals themselves.
‘Care should be organised in networks that can be accessed in a multi-sided and plural way, rather than top-down’
So care should be organised in networks that can be accessed in a multisided and plural way, rather than going through top-down processes that are slow, expensive and not adaptive to an individual or a community’s fast changing health needs.
The second task was to establish a care model designed to support this distributed network of health and social care, so that it can be adaptive and organised around individual patient need.
Health and wellbeing has to be personalised to the individual, so that they can fully engage in co-producing their care and in taking responsibility for their own health. The CCG’s model is based on how this network of care works with the individual. It is termed “mutual networked care” because ownership, responsibility and benefits are shared mutually (see box, below).
This new approach has led the CCG to restructure the system by bringing together all population based care into one set of integrated services based upon the registered populations with general practice.
GPs are at the heart of this model as the key coordinators of care. The initial restructuring builds a network of connected services around a person, creating a practice orientated multiprofessional team coordinated by the practice.
The wider networks of health and social care can then be engaged around patient need as required, in a timely and minimalist way that promotes independence and wellbeing, while recognising that demand, capacity or economies of scale require some aspects of care to be fed into the team from a borough-wide level.
Principles of mutual networked care
Shared ownership: Each patient registered with a Dudley GP practice is by implication a member of Dudley Clinical Commissioning Group, as it is a GP membership organisation. All public services are similarly owned by British citizens.
Shared responsibility: Service users and staff have a shared responsibility to work together to co-create the best healthcare and wellbeing provision. This means shifting responsibility from “the system” providing care to dependent individuals, to achieving “mutual responsibility” so health, social care and wellbeing are co-produced by providers and receivers of care.
Shared benefits: The benefits of the NHS and other public services are mutually shared between stakeholders. We aim to achieve defined outcomes through participative engagement - both for the whole community in improving overall health and wellbeing, and for individuals in their personalised care and wellbeing.
Any change requires senior buy-in from all organisations. Developing the services around the patient can be good for patient care and enable overall efficient and effective delivery. But individual services have to change for the benefit of the whole.
An initial barrier to the change was that organisations would resist if they perceived the restructuring would cause a worsening in efficiency for their own individual service. Although the model was agreed in principle by all parties, it had to be proven in practice.
We started with five “early adopter” GP practices and now have 12 practices with integrated multiprofessional teams. Our aim is for all these teams to be established by early 2015.
There has been a consistent enhancement of good practice among health professionals, and a dedicated social worker and mental health worker are now also involved.
The most appropriate coordinator of a patient’s care leads the discussion. He or she raises concerns, suggests solutions and agrees an approach to care. The patient information system is accessed during discussions, so the most up to date information on the patient is referred to and their notes can be updated.
Before the CCG adopted this new way of working, these kind of conversations may have taken place but in an uncoordinated way and without all professionals at the same time.
Voluntary sector link workers form a vital element of this model. Thinking outside the normal boundaries of health and social care, they provide a lifeline for many patients and link our patients with the services that “care for the soul” and provide social interaction.
These interventions and the active management of people’s needs are integral, not just to recovery, but to ongoing wellbeing.
One of the patients reviewed was a lady in her late forties. Her mild learning disability means that she needs support from a live-in carer, who was a family member.
She had been diagnosed as having depression, caused mainly by a lack of social interaction.
‘Voluntary link workers help patients to make essential links back into the community’
The voluntary link worker made a home visit to the patient and, as a result, she has been given advice on finances, access to local groups to explore her interest in arts and crafts, and an introduction to a health trainer to help her lose weight. Action plans were co-produced with the patient and feedback given to her GP and uploaded onto her medical notes.
These link workers act as navigators for patients to take those first steps to ultimately take control of their own lives. They help patients make essential links back into the community, improve self-esteem and grow in confidence.
This support is breaking the cycle of dependency on health and social care services in Dudley.
We also recognise that mere structural and process changes are insufficient. We also need to address the emotional connections that people and organisations have to the services and give them a sense of purpose.
An “organisational development” initiative has been implemented to engage all 600 community staff, including social care workers and the voluntary sector. It begins with a one day workshop of groups of 12 to communicate the guiding principles, share the new structures, explain the benefits, and help individuals and teams to make this process successful.
There is also space to reflect on their personal development needs to change the way they work, and use this opportunity to build networks across boundaries.
Paul Maubach is chief executive officer of Dudley Clinical Commissioning Group and Simon Western is a leadership and strategic consultant