Jackie Daniel: Developing organisational forms and governance models

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Jackie Daniel

Jackie Daniel, Chief Executive of University Hospitals of Morecambe Bay NHS Foundation Trust, shares lessons on creating a population health system.

Jackie Daniel: Developing organisational forms and governance models

This presentation was recorded at our event on Multi-specialty community providers and primary and acute care systems on 7 June 2016.

Transcript

I probably should start by saying a few words about my reaction to titles and things like that. I guess it comes from … and I’ve taken the lead in the bay for kind of communications and trying to get some of the messaging right, using all sorts of media.  For me, both the population and staff really don’t get all these buzz words: STP, MCP, PACS - they just don’t get it.  So we are Bay Health Partners, our strategy is better care together and the way we work we call it the Bay Way and it’s kind of as simple as that.  We don’t refer to ourselves as a vanguard or any of that.  It just seems to work at a local level.  I also probably should say before I start, that I think it’s really all about the people for me, all of this.  I don’t want to though gloss over some of the really quite technical aspects of what we’re trying to do, so all I would say to you is if you want a load of that, go on to either the Better Care Together website or My Own Trust website and you’ll see no end of stuff around the Memorandum of Understanding, some of the models, some of the designs that we’ve got on pathways etc., etc., so go there if you’re interested.

You will know something about Morecambe Bay I’m sure. I walked into the organisation four years ago and it wasn’t good, we were renowned for many very bad things.  Most of you will have heard about the Kirkham inquiry into ten years of tragic consequences of poor health provision.  But it wasn’t just maternity, there were other failings.  We kind of spectacularly fell over in every sense and I think trying to kind of sum it up when I arrived in the Bay, there was just lots of broken contracts with the public, with staff particularly, with partners, it was not a great place to be.  But it was kind of a good way to start, it was a real watershed moment and what an opportunity to recruit whole new teams and work in different ways.  It kind of coincided with the abolition then of SHOs and CCGs were being formed.

I think that is relevant because we were all new leaders in the Bay and looking back now with the benefit of hindsight there was something really magical about that moment, you know when you just think the planets align and this is meant to be. But trying to find a solution for that, for why it was broken, was tough.  I’m really interested from the earlier presentation about life in Wales, I have led organisations just on Offa’s Dyke so I know a bit about the differences there are.  We’ve got a lot in common in terms of geography.  Obviously it’s beautiful.  I mean the one thing about working in the Bay, it is absolutely beautiful, right on the edge of the Lake District national park, really spectacular.  But massive challenges.  So we serve a population of about 360,000 and the drive time between kind of Lancaster through to Kendall in the middle and right out to Barrow-in-Furness, it can take anything … one and a half hours, it can take more than that, it’s well over 50 miles.

So trying to get joined up care and trying as an Acute Trust provider, to provide care across three hospital sites, well five sites if you count some of the outpatient sites, within tariff is just a nightmare. I’ll say a bit more about that in a minute.  I remember in our first CQC inspection which we spectacularly failed, we’re now out of special measures, but we were … within six months of my arriving, I wasn’t surprised that we ranked as we did and the CQC inspectors talked about, why haven’t you got bay rotation working seamlessly.  Well, okay I’ll drive you round the sites and we’ll look at some of the rotas and I’ll try and explain why.  So a huge challenge.  There are 11 partners playing into this population health system, four FTs, two local authorities, two CCGs, an Ambulance Trust.

That says something about where we were in the past because if you look at that makeup of provision you kind of couldn’t make it up, talk about how you overcomplicate what should be really simple. That was because actually relationships were really poor.  So the commissioners in the past would do anything but commission it with the Bay Trust.  So that’s some of the rationale for why we’ve got what we’ve got.  I use this diagram quite a lot because you can imagine what it was like going into the Trust four years ago and trying to get a handle on the chaos that was reigning, massively over-regulated, no team, the board had completely gone, there were so many issues that we were trying to focus on.  I use this as much today, four years on, when we’re in a much more stable position, but this is the splits that you do in a literal sense most days, and my team do in a literal sense most days when you’re working on delivering A&E targets, making sure we’re delivering RTT etc., etc., some of the basics in inverted commas that very few Trusts at the moment are managing to succeed in, while also working through a transition path and trying to get into the transformation space.  It’s a really, really tall order.  Balancing a kind of Triple A money quality experience.

I feel like I live in a world of Venn diagrams and I’m sure my partners would say that as well and it’s a real juggling act. But one of the things that we did very early on was talk about what were the stakes in the ground, what would we not go beyond and for us in the Bay, our stakes in the ground were that we would have two emergency units so we’d provide emergency services and obstetrics at both Barrow and Lancaster.  We’ve got a small intermediate hospital at Kendall which is actually quite important for flow, but those were our stakes in the ground.  I keep getting challenged by you know, at the moment a tough financial call, can you pull one of your stakes up.  Absolutely not.  If you come up to visit us I hope you’d understand why.  Everything else is up for grabs.  So we have got an acute care axis which flows from one end of the geographical patch to the other.  My strategy is to make my hospital as small as humanly possible.

So as part of the plan this year we’ve taken out 65 clinics a week, we will close three wards at the end of this year, and that absolutely is the strategy. At the moment there’s a financial deficit in the Bay so my turnover is about £300 million, the Bay turnover is about £700 million and of course we’re doing what many of you will be doing which is trying to rewire that diagram so we have one single budge.  My task is to shift some of the spend out into the community, primary care and into mental health provision and actually this year we’ve actually spent quite a lot in social care provision and I know people tell us we shouldn’t but you know, we need to keep flow going and we need to keep patient safety where it should be and so we have invested in social care.  It’s really, really interesting talking to other people up and down the country about the reputation of kind of big bad acutes.

I don’t know that I’m now unusual thinking about population health, I’ve appointed my medical director, the director of public health and I remember some of the clinicians when we were going through the recruitment process, saying you’re appointing who, you know, you need an emergency physician or a anaesthetist, or no I need a … I need someone who understands population health and who can help us join it up. So I think the role of the acute, we are the largest kind of provider if you want to think about it in those terms, across the patch.  It’s really, really important we kind of lead the way and really shift the mind-set in acute provision, which is really challenging, but very doable.  I think after three years it finally feels like we’re getting there, where hospital clinicians of all disciplines are kind of working out of hospital, probably as much as they’re working in.  So it’s really interesting.  It is a real mind-set change.

I just want to say something about STPs because I think we could try and be a bit too clever with what we’re being asked to do at the moment and our STP works down into Lancashire, so it’s quite a big geography and there are kind of five footprints in our STP, and I think that’s a neat way … what I’m saying to anybody who’ll listen is, think about the footprints. If you try and swallow the whole elephant in one go I think you’re going to fall over because if you think about trying to create relationships across quite a small patch, is as difficult as we know it is, trying to do that across and STP footprint I think is really hard.  But what I would say is, it’s essential because … I showed you the map there, we are entering into strategic partnerships with Manchester and with Preston in areas like maternity and I look at it as a bit of an umbilical cord for our system.

Our population obviously need to access specialist care, you know it’s the lifeblood for some of my clinicians and some of my staff who are working in small units in quite isolated circumstances, so it’s proving invaluable. We’ve actually got rotations going on right across that patch, it’s really, really important I think to think about some things in STP.  I wish the planets would align, they keep aligning and then they go out of sync again and I feel like I have a total eclipse.  We’ve had all sorts of things at the moment that are not aligned.  So our money was really broken.  We started with a quality catastrophe.  We fixed it and we spent a lot of money and at the moment I’ve got an underlying deficit of £30 million, that’s the price of putting some of that right.  We did apply and monitor that was, made a rule around local price modification, we are the only Trust I think in the country that got through that policy.

We were awarded cash support through a local price modification, but it kind of don’t fit because of course monitor as was, ticked the box, you go through the policy, but the Treasury and the DH didn’t quite know how to allocate it. The reason I’m sharing that story is, the planets still are not quite aligned, so we’re talking with NHSE and NHSI about how to put the package of support for the Bay together.  They’re really trying I would say and I mean that in a positive way, they’re really, really trying to work together, but they’re not quite joined up.  It is quite … when you’re trying to build relationships it can be quite divisive between commissioners and providers.  I know that single issue … I just keep saying, let’s bury local price modification, I will not utter those words ever again, but what we do need is some sort of transitional support.  So in our financial model it look like we’ll need that for probably three, four years, beyond which we’re saying, no we need to take care of the Bay pound and redistribute resources and live within our means.

Let me just say a bit more about the challenges of creating this new world. So I talked about relationships and we have really, really been on a journey and we’ve fallen out, we’ve exchanged words as leaders in the Bay.  I’m really pleased to say we’re still working together.  But it really, really does take time.  People say to me at the moment, how much time Jackie, are you spending creating this new system and I think it’s probably half my week, working as a system, half working with a foot in the organisation and we’re now … we come together for a day a week as system leaders.  I’ll say a little bit more about that.  It’s constant, it never stops.  There’s competing priorities between the stabilisation and transition and transformation, a real juggling act.  I’m very, very lucky, I’ve got an executive team who are all very experienced.  I can play many of them, not all, but many of them are playing system roles in the leadership team and as well as their day job in the Trust and that’s been a real, real balancing act.

So my medical director leads for population health in the Bay with other clinicians and other … particularly obviously public health clinicians from the local authority. My finance director is working with the commissioner at joining up the framework for the money so that we can work on the capita costs and try and break some of the old rules and work in new ways.  My director of strategy actually is pretty much whole time creating what we call the common platform for integration.  But it is a real tall order and not everybody kind of gets it so I think that’s one worth thinking about as leaders.

Lastly, kind of cards on the table, I think there’s some points really well made already this morning about constantly just coming back to why we’re in this, why we’re doing it, particularly when the planets are not aligned and you’ve got a solar eclipse and you really can’t … you just think how … it’s interesting. I often ask myself you know, could we go back and we couldn’t now, we’re too far advanced, it would be almost impossible to go back even if when it gets really, really scary I feel like I want to because I know how to lead an Acute Trust.  Leading a system with other leaders is really, really challenging.  I’m not great at shared leadership, I’m kind of, you know … those of you that have worked with me before know that I like to be leading, so it is really challenging.  Our evolving programme … so our model is absolutely based around the Triple A but the model that we have for our programme of work is around these three areas.

So the first is, the clinical join-up which is integrating services and we’re doing what many of you will be doing around integrated communities, we’ve got place based teams in the three main areas of Lancaster, Kendall and Barrow and we really are joining up all the care provision. We talked this morning about the voluntary sector, about engaging on areas like housing etc.  It’s just a bit beyond our bandwidth at the moment but we want to include all of that in the work that we’re doing. But let’s just not get too clever and get some of the basics right.  The common platform is a term we use for integrating technology, informatics, where we’ve got shared procurement, we’ve got a one workforce strategy.  We are looking at one estate strategy.  We’ve got more real estate than you can shake a stick at.  Not much of it is in good function and we probably need to get rid of at least half of it.

But that will close quite a bit of the financial gap, that’s the plan and it will obviously bring us closer together in terms of integrating organisations. But more importantly, it will deliver real benefits for the patients.  The SCS development is the third area of programme of work, this is where we’re working with partners.  We’ve got two partners working with us on the governance structure, the Governance Institute and Capsticks.  We’ve got a big programme of work around OD where we have worked with Aqua to develop a common methodology, again, really, really important in that PDSA cycle about learning how to learn and work together.  So we’ve invested a lot of time and energy into that.  And to try and work with the leadership team, although as we move forward through to … you see I’ve used that word, accountable care organisation, I don’t know what else to call it, but as we move into more formal structures we’ve got some key gateways this year.

So in September we hope to have finalised our governance framework, paying attention to things like risk and the management of risk, the escalation, etc., etc. We hope that by April next year we’ll be in a much more formal structure and some partners may choose to fully opt into that, I think the majority of the acute provision will, the community provision almost certainly will, quite a lot of primary care in the Bay will, part of social care in the Bay will by that point.  So we’ll be … you know, when we talk about Bay Health Partners it really does feel real.  So just to finish then, I think transitioning, it feels really different and I’ve been in healthcare all my career, but it does feel really, really different working in a system rather than an organisation.  We’re getting used to that and we’re learning how to make it work, but I think nationally we need to talk a lot more about it.  I think you underestimate the time it takes absolutely at your peril and you’ve got to put real resources in.  So I haven’t talked about some of the technicalities.

We’ve got a big PMO, we’ve got a lot of shared resource, we’re got a lot of shared project and programme support firing this from the centre. But you know, we’re treading new ground and focusing on population health.  Any of you that are interested, we’ve got a major programme running for our workforce called Flourish, just getting people to walk more, look after their mental health, look after their nutrition.  We’ve removed all the sugar we can find from every space in the hospitals and trying to push that out.  So some of this stuff is kind of ground-breaking, it does feel really exciting.  Can I give you a 100% guarantee that it will work?  I don’t think I can.  Do I think it’s providing better care and much more fulfilling?  I think the thing that I’ve noticed in the last year in particular is how on their toes the staff are in the Bay, they’re really, really energising, they absolutely love it and the population are really getting engaged in it, feeling like it’s their hospitals, so creating that abundance of thinking about, it’s our resource, it’s not my hospital.  My single job is to create an environment for the staff to flourish and for people to get really great healthcare, but it is a very different way of thinking.  So I’ll stop there. 

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