Demand/need is increasing. Austerity is taking its toll, adding to the pressure of the predicted impact of demographics and co-morbidities. GPs are stretched to the limit (one GP told me she had consulted to 80 people in one day). But this isn’t the case everywhere, some services are adapting.
We can wait for disruptive innovation from pharma or technology (be it online GP services, to no end of maps and apps to support dementia) to radically change behaviour, and there are champions of this approach who think it is the only game in town to really radically transform the NHS, who think we can’t wait for adaptive social change. I don’t agree, its not the only innovation that can generate significant shifts. There are examples (not many as yet, but they are running against the grain) of social innovation in primary care and communities that is stemming the flow from communities to A&E, and increasing reach without increasing costs. These result from a new relationship between public and third sectors and communities; and adaptation based on inquiry into better ways of working, using data.
Just to be clear as we see another drop in the % of DH funding going to primary care, there are two gatekeepers to NHS services – GPs and A&E. This has to be a significant focus of attention for any systems change efforts.
The biggest problem is that the NHS is playing catch-up and has needed for some time to focus on (alongside the disruptive innovations) a few key interventions that will change the way local health is organised and delivered. These are:
- Data availability to support innovation (not for performance that’s different), and a culture of curiosity and peer review
- Asset based community development and coproduction – de-professionalising neighbourliness, de-medicalising wellbeing.
- Diversify the professional workforce based on need.
- Learn from others – steal with pride.
Most social innovation is incremental requiring curiosity, inquiry, testing, adaptation and contextualisation. This means that social innovation will take time, and the clock is ticking. Starting can’t want any longer.
Its fascinating the amount of reports and evaluations into NHS social innovation that cites the same lessons over and over again, and which are repeatedly ignored, as the dominant hierarchical culture of public service, wedded too and shored up by the ‘steady as she goes’ approach, is challenged by the adaptive challenge of networked collaborations.
Here are two types of evidence – evidence-based stories of those local health systems that are making it work; and evidence from the evaluations of attempts to innovate at systems level.
Lets start with a story
Evidence: A Story of Reimagining General Practice
- Generated masses of community asset – with the partners investing in a Health and Wellbeing Centre, which as a charity runs over 67 new or extended health, social and voluntary service and volunteer run programmes, with 19 groups run by over 50 volunteer champions every week.
- Recognised the need in care homes for one GP, and cut admissions dramatically with an 80% reduction in urgent care visits; 25% reduction in hospital admissions.
- Understood that increasing access reduced demand, and opened its doors through both booked appointments and walk-in and has reduced overall appointment demand by 26.5% (before adjustment for 20% list size increase over the same time),
- Reviewed their caseload and diversified their team accordingly, with an appointment model where professionals on duty review the patients needs (as identified by the patient when they check-in) and call off the next patient in the queue that they are competent to handle.
And in doing so has grown its list size from 8000, to 13332
This shows us what’s possible. It tells us that there are very few interventions required as described above, but they require a changed mindset to bring together citizens as equal partners, to professionally review of clinical and management practice based on data, and to test and adapt continually.
So what happens when health systems across primary and secondary care try to innovate? What happens at scale?
Evidence: A Review of Integrated Care
For years the NHS and Social Care system has been grappling with Integrated Care, and it remains an ambition for many health systems. Reviewing 5 evaluations of Integrated Care programmes revealed that it helps if:
- There is a history of collaboration – where the partnering organisations have been trying to work together for some time.
- Citizens are part of the diagnosis of the problems and determining the solutions from the start.
- There is dedicated time to learning together.
- The systems leaders don’t get distracted onto other projects or issues, but generate focus and attention and consistency for the duration.
- There is some start-up funding to generate head-space.
What consistently got in the way was:
- The difficult in data sharing.
- Lack of clear processes for decision making across the partners.
- Setting expectations too high, generating disappointment when these weren’t achieved.
- Lack of ownership across all partners and at all levels.
- The lack of experience in and attention to securing citizen partnerships.
- The vacancy of support from the centre to unblocking issues that cannot be resolved at systems level.
And what continues to be problematic is:
- The lack of ongoing evaluation to capture the impact over time (these innovations take 5 years).
Across them all it appeared that:
- Evidence didn’t seem to count – it wasn’t part of the service development, and so there wasn’t a strong enough commitment to an evidence-based analysis of the real issues and the impact of any changes. It was unclear how the integration sites reviewed had learnt from others (including form the evaluations of other integration sites)
- We are behind across the NHS on data – the availability and quality of data for innovation and improvement, and the shear ability to share data.
- Citizen participation doesn’t just happen it needs planning and mindsets need addressing. We cant wait for professionals to decide if they can, or should involve citizens – its as basic condition.
- Improvements are not likely to be found in the short term, it takes time.
At minimum the NHS needs to address:
- The issues of data quality, analysis, accessibility and sharing across the system
- The GP ‘business’ model – bringing improvement, coproduction and emergent change practices into the reshaping of primary, community, social and third sectors to a health and wellbeing service that complements and supports local community capacity
- The role of specialist expertise in a ‘home-based’ model.
- System-wide development of community assets
- The ‘top’ in real service to the frontline
You can see more on our Lab visit to Leeds here
 that’s not so say actual money decreased its just GP spend grew 1.5 per cent – while overall spend grew by 3.4 per cent – HSJ 21st July