Are we a New Model...?

Our latest Darzi sojourn brought me into contact with a number of organisations who are setting themselves up as New Models of Care. On the surface, it would seem as though NHS England coined the term around 2014 with their strategy for delivering Simon Steven’s Five Year Forward View and exemplified by their Vanguard programme. However, they have termed their programme ‘New Care Models’ rather than ‘New Models of Care,’ the difference may be subtle but it is important.

Looking further afield we realise the concept of New Models of Care has existed for some time and it certainly predates NHS England’s version. When we look at examples like South Central Foundation (Alaska), Intermountain Health Care (Utah) and Jonkoping (Sweden) these organisations have been delivering health care to their population in a distinctly transformative way.

What does it take to be truly transformative and do we think NHS England has it figured out? Delving into those examples above it becomes quite apparent that they have managed to revolutionise healthcare for their local health economy by adhering to some core principles, some of which are explored below.

The South-Central Foundation for example dedicated an enormous amount of time to scoping exercises with its key stakeholders, we’re talking a couple of years of engaging with their citizens before launching their programme of transformation. Their service users are treated as ‘customer-owners’, akin to a co-operative and these exercises in engagement didn’t end with the roll out of the programme, it’s a continuous ongoing process and the organisation appear to be deeply embedded within the local community. In doing so they have formed a deep understanding of their population’s need and have been able to create a solution that was locally generated and understands the context within which it operates.

A few examples that highlight this perfectly:

The South-Central Foundation offers traditional Alaskan native healing services in addition to conventional medical services.

It’s primary care centre in addition to its health role also functions as a community centre.

Large ‘Talking Rooms’ instead of traditional consultation rooms to accommodate as many as 10-15 individuals, particularly of relevance when dealing with end-of-life care situations and sensitive to the extended family structure of most of its ‘customer-owners’

South-Central Foundation Health Centre

Moving on to Jonkoping County Councils programme of health reform. It was centred around a shared vision agreed upon by the key stakeholder and a commitment to act. In English, it roughly translates to “a good life in an attractive country,” which reflected their holistic vision to deliver quality of life rather than just health care. Through their collaboration with the Institute for healthcare Improvement they turned their focus on to quality improvement and imparted the skills needed to drive this on to their staff. They provided their staff with the headspace they needed in order to innovate and drive change. In fact, a whole building, the ‘Qulturum’ was dedicated to providing this headspace for staff and of course their return on investment as a result has been impressive. They have managed to create the perfect environment for clinical leadership to emerge and develop amongst their own workforce.

The 'Qulturum'

Finally taking a look at Intermountain, which is perhaps the largest organisation of the three described. It comprises of 23 different hospitals, 150 clinics and 32,000 employees. Even by our NHS standards it’s an impressively large structure, our largest Trust; Barts Health comprises of 5 hospitals and employs 16000, pales in comparison. Anyone who’s worked for the NHS will have shared my frustration at the lack of interoperability amongst IT systems and the great difficulties this then poses for delivering care. Intermountain have recognised the power of information; for how can you go ‘there’ when you don’t know where ‘here’ is?

What they have done incredibly well, through the use of a robust clinical information system (at forty years of age, they must have one of the oldest EPRs!) is to really understand their own performance. The insights they are able to generate utilising their clinical information system which spans their entire organisation is vast. It has allowed them to target their efforts, much like Jonkoping, on quality improvement with a laser-focus.

In analysing what makes these systems such high performers and what makes them ‘New Models of Care,’ we as a group settled on a number of features:

  1. Focuses on the needs of the population

  2. Locally generated solutions that take into consideration the local context

  3. Collaborative in nature

  4. Changing of traditional roles (who does what and where?)

  5. Clinical leadership from emerging leaders (relational)

  6. Providing the headspace for change

  7. Shared visions, goals and expectations

  8. Commitment to act together

  9. Information is key (Understand where ‘here’ is to get to ‘there’)

  10. Attention to spread

Now this may not be the perfect list and I’m sure parts may need adding or subtracting based on what is being asked but as a starting point we could do far worse. In the examples, I’ve described I’ve focused on a particular feature from each but don’t let that fool you, they all share some aspect of the features above to greater or lesser extents.

Now looking at NHS England’s ‘New Care Models’ programme, their learning from the Vanguard sites into what it takes to become one seems to focus a little too heavily on the actual mechanics needed to set up a ‘New Care Model’ and less so on how a ‘New Care Model’ can be truly transformative (aka a ‘New Model of Care’). However, they should be credited for paying recognition to some of the features we’ve defined above: Understanding population need, taking a collaborative systems leadership approach, having a shared vision and allowing the headspace to enable change.

Presentation to KSS Darzi's from NHS England 'New Care Models' Team:

Lessons learnt from the programme

10th January 2018

So that begs the question, are we a New Model of Care? That’s rather difficult to answer for a number of reasons. Firstly, given how early we are in the programme it’s not immediately obvious how things might turn out. Secondly, we as a Living Lab aren’t strictly tasked with the job of delivering health or care. Instead we see ourselves as an environment within which citizens can co-design innovative solutions for the delivery of health and care. With that in mind as I measure us up against the criteria above I think we fit the bill on a couple.

We are certainly focusing on the needs of our population, in fact the majority of the work undertaken thus far has been scoping exercises with the residents to really identify their individual needs and to build common themes. As a result, the local context is held at the forefront but I would argue that the Digital Health solutions aren’t necessarily locally generated but perhaps they will be locally adapted for use.

Though the project has been collaborative there is no convincing change in traditional roles as such, the professionals remain on one side whilst our citizens on the other. I suspect the nature of the intervention plays some part in this. The word ‘Digital’ can carry with it negative connotations, particularly in the eyes of older citizens and can automatically put up barriers to inclusivity. This is a challenge of ours but through collaborative working with organisations such as Citizens online and Digital Brighton and Hove we hope to create a legacy where citizens do feel more comfortable with the use of Digital technologies, eventually to the point where they can contribute in meaningful ways to the design of it.

As stated above, information is key, knowing where is ‘here?’ is key. To truly say we have achieved this would be to say that we have freely shared information with all relevant stakeholders and sadly that would not be true. However, it’s also true that establishing relationships and trust take time, particularly when one needs to take into consideration the historical context for some of these relationships. One hopes as the project evolves some of these relationships become established and sharing of information can occur. Such is the nature of programmes that are being driven by a particular stakeholder as opposed to being centrally mandated or collectively owned. A perfect example of how and why leading across systems is tough. Until this sharing of information can occur, making a case for scale and spread is difficult.

As much as I would like to think we are acting as a united front in the delivery of the Living Lab I would suggest that we have found common ground with our stakeholders and have an overall shared vision for what it is we’re trying to achieve. The steps taken to achieve that however have been the individual decisions of key stakeholders, chiefly ourselves. Though there is a commitment of sorts, this has been entirely spearheaded by the award of a Darzi Fellowship and the resources this has brought to the programme. In the absence of such an award I am doubtful there would have been the same commitment to move forwards with the programme.

Through our inclusion in the Darzi Fellowship, I would testify to the fact that the programme has allowed me to develop as an emerging clinical leader. The Living lab itself has identified a new opportunity for innovation and citizen centred design in Brighton and Hove, this has naturally allowed my sponsor to emerge as a regional leader in this respect. Were it not for the legacy of the Leading Places programme and the support of the Darzi Fellowship it is uncertain if this would have been possible. Therefore, I wonder if this comes back to the issue of headspace, only by being in this privileged position as a recipient of a Darzi Fellowship have I been afforded the headspace to develop as a clinical leader and really understand what it takes to be a New Model of Care. Reviewing many of the Vanguard programmes this seems to be a critical component for why they were able to achieve what they have.

On balance, I feel we meet some of the criteria of a New Model of Care but are left lacking in others, however I am hopeful that at this early stage things will continue to grow and evolve. The areas to focus on are how to widen our collaborative efforts with key stakeholders, gain firm commitments to share information and act together and to begin future planning as the Darzi Fellowship comes to close. These will be some of the challenges that lie ahead of us but having identified them early into the programme we have given ourselves the best possible chance to deliver a New Model of Care.