Barking, Havering and Redbridge launched a range of initiatives in the community, primary care, A&E, and the hospital itself as part of making new care models a reality. By Claire Read

To borrow from George Orwell: every area of England has healthcare challenges, but some have more challenges than others. Barking, Havering and Redbridge falls into the latter category.

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Its diverse population of 750,000 is set to increase by 10,000 over the next nine years – and 22 per cent of that increase will be in the over 75 age category. Obesity levels in the area are significantly higher than elsewhere in London, and half of all of those over 75 have a long term condition.

’We aren’t victims, but we aren’t heroes either’

The hospital is in special measures, accident and emergency performance has been a problem for the last decade, primary care access and quality is a worry, and if nothing changes the expected result is a £400m deficit.

“We aren’t victims, but we aren’t heroes either,” Conor Burke told delegates at an HSJ/McKinsey Summit on making new care models a reality.

Advancement in care delivery

The accountable officer at Barking and Dagenham, Havering, and Redbridge Clinical Commissioning Groups added: “What we need to do now is crack on and deliver solutions for our local population, for individuals, and change the way care is delivered. We’re ambitious to do the right things for our population. It’s a journey, but I think we’ve made a start.”

One of the most notable areas of progress is A&E. Two years ago, system leaders came together to establish an urgent care model.

It demonstrated we could deliver change

“We really focused on the A&E target and how we could make a compelling difference to performance,” Mr Burke explained. “There are now a range of initiatives that we’ve put into place in the community, in primary care, at the front door of A&E, in the hospital itself, flowing through the hospital into discharge and working with our community partners, with primary care, and with our local authorities to demonstrate highly productive system flow.

“In July last year, and across the second quarter of 2015-16, for the first time in seven years the trust achieved the 95 per cent target (95 per cent of patients attending A&E discharged, transferred or admitted within four hours). That was a fantastic achievement for us – it might not feel like that for other providers in the audience, but it was for us. And it demonstrated we could deliver change.”

An important enabler of this new care model was “having one version of the truth in terms of data,” Mr Burke reported. “Measuring systematically at all points of interaction and across the system how we could hold each other to account in terms of system-wide delivery, whatever organisation you worked for.”

Technology is key

The value of data and information is also a key focus in West London CCG. Richard Hooker, clinical lead for the organisation’s integration project for over 65s – one of nine integrated care pioneers in north west London – explained technology is at the heart of the model.

“Ideally we will have an IT-based care plan shared in real time across the whole landscape, with a single point of access and with the service users and those around them becoming expert in their care.”

Unless we get the IT right and the data flowing properly, we’re never going to succeed

This was certainly not without its challenges, reported Dr Hooker. “There is a lack of IT integration. Tim Berners-Lee (the computer scientist who invented the worldwide web) is obsessed with integration – I wish I could phone him up and say please come and help us out, because I think we need that sort of disruptive moment with the IT. I think unless we get the IT right and the data flowing properly, we’re never going to succeed.”

“Data is going to be absolutely critical for us,” said Mr Burke of Barking, Dagenham, Havering and Redbridge. “We have lots of experience in that, but we just don’t do it well enough. And so as we drive forward, the measures, the metrics, holding each other to account, is going to be really, really important.”

Leadership drives change

So too, he said, was political and clinical leadership. Just before Christmas, the area applied to become a sub-regional pilot for devolution in London and, through that, is developing an accountable care organisation.

“At that top of the business case development process, we felt it was really important to have the most senior leaders of the system running this,” Mr Burke reported.

It’s about focusing on people and the patients and saying we’re all in it together to be able to make a difference

“One of the key bits for us is having the political commitment in order to be able to take devolved power and hold each other to account. If you don’t get the local authorities politically onboard with the big changes you’re going to make, whether structural or service, it gets in the way.”

In Barking, Dagenham, Havering and Redbridge, the work is therefore chaired by a local authority leader. “The group meets every two weeks as an accountable political and clinical leadership to drive this change forward. I would say in some ways that is the most critical part [of the project].”

An audience member suggested this sort of setup necessitated a period of bereavement for staff – of accepting the traditional strategy of carving something up so everyone goes away feeling a winner is no longer appropriate.

“There’s continuous loss and grieving about various things in terms of performance and delivery,” commented Mr Burke.

“I think it’s about focusing on people and the patients and saying we’re all in it together to be able to make a difference. On one level, we have to go through a process of dealing with the system in the way it’s currently designed which we all I think agree isn’t the most effective way of delivering better care. So it’s a commitment from the right people at the right time in the system.”

He felt there had been this mindset shift in his area. “I’ve seen our local authority colleagues and local authority chief executive say I will commit personally to fulfilling that cost pressure, at some significant cost to their organisations. Now that is a change in behaviour I’ve never seen before in the system.”