Paul Maubach, CEO of Dudley CCG, discusses the success of Dudley's integrated care model, which brings primary care and allied health professionals together in teams based around population cohorts.
This presentation was given at The King's Fund event Enabling allied health professionals to lead and shape new models of care on 8 December 2015.
So what I’m going to do is I’m going to give you a bit of context first in terms of some of the challenges and issues within which we’re operating which will get me a bit depressed, I hope it doesn’t get you too depressed. And then I'm going to talk to you about our model of care as one of the national vanguards and what the opportunities that is creating across the whole system including the opportunities for AHPs.
So some of this it’ll be obvious to you I’m sure you will have seen all this before, but the first context within which we’re operating is what’s changing with our population? We are a society which is getting older, the demographics show that our elder population is increasing at a very significant rate, and when you look at our utilisation of health care then it’s our older population that consume considerably, disproportionately more resources than their proportionate share of the population, which presents us a problem moving forwards which is an environment where it’s not even a case of no more funding, it’s actually reducing funding when you take the wider health and social care context. Then we have a very significant challenge on our hands about how do we meet the needs of our population?
And the increasing demographic within that is that we have an ever rising cohort of patients who are living with multiple complex conditions. And when we look at our two percent of most complex patients within Dudley the vast majority of those are in the older age population and they consume substantially additional resources. Most of them have at least three long term conditions of one description or another and when we look at what are the three most common conditions that come together in Dudley it’s hypertension, depression and then musculoskeletal conditions. So as a starter for ten we need our pharmacists, counsellors and physiotherapists to be working better to get that.
And that’s really the key point about our model of care, is when you look at population need and the way need is changing our population are presenting with multiple problems. So what we need is academics combined coordinated multi-disciplinary response, people working together rather than working independently.
As a CCG it’s quite a challenge when we look at how we distribute our resources at the moment, and Sam talked earlier about we’re moving away from organisations to a different way of working, to a care model, but I think it’s important to start with actually what’s the context in terms of where we’re at at the moment? And our system is defined by organisations, so it’s not defined by population need. We actually contract the services on the basis of organisation, not on the basis of how services should work together. And when you look at the history, over half of our resource are spent on acute secondary care. When we look at the way the historical incentives and contracts have driven investment, what we see over the past is that the high cost area of spend in secondary care are the areas that have had additional investment. And the front end if you like of our system which is primary care has had no additional investment but has absorbed substantial growth to the point at which now actually it’s almost beyond breaking point.
So we have, when you think about the characteristics of the design of the system at the moment, certainly in Dudley we have one acute secondary care organisation which operates out of three facilities, one main one and two small ones, the rest of the system primary community mental health, community services, social care operate out of over 80 locations multiple different organisations funded in different ways, it’s fragmented and not coordinated. So one of our key challenges, we’re presented with a population which has multiple complex needs, we need a much more joined up and joint approach to the way we respond to care and one of the challenges that we face is that we’ve got to change the investment strategy and the incentives to actually ensure that there’s more balance in the system. At the moment it’s heavily distorted and over reliant on secondary care. And that’s not just the contracts, it’s actually the whole design, even though the national programme is sponsored by all the different arms’ lengths bodies, actually the whole regulatory contract incentive process at the moment gears towards one part of the system.
Just as an illustration every CCG at the start of this financial year, after all the contacts are signed, got a letter from NHS England telling us we needed to spend more money on elective care. Why is that? Because there’s an NHS constitution standard around referral to treatment times, but also more importantly it’s easy to monitor and track a model. I didn’t get a letter saying for example that we needed to do more on our speech and language therapy service even though it was really severely challenged and we’ve had to do a lot of work this year to try and build a service back up. And why didn’t we get that? It’s because there’s no national data on it, there’s no national attention on it. So there is a real issue about trying to deliver for the future a clearer balance in the system about what our priorities are across all ways in which we work. And that at the moment, the current way of working drives against the model of care and the need to the population in terms of the way we want to work.
So for Dudley our model of care, we try to keep it very very simple and it’s essentially based around the idea of a person registered with a practice working on a population basis. And then what we’re doing is we’re wrapping services around that, trying to meet the needs of the population. So it starts with the fact that there’s a significant cohort of population that have multiple complex needs and they need a coordinated response. So what we’re doing is we’re bringing services together working with the same population and that’s really the key point for us, is that what we’re trying to achieve in every change that we’re making we’re first and foremost looking at are there ways of enabling the person to take more control over their own health and wellbeing? And secondly are there ways of enabling each member of frontline staff to work better together with those individuals and are we clear what outcomes they’re trying to achieve? But most importantly how are we bringing staff together who need to work together on a set of shared out comes so they can work more effectively together?
A good illustration of the way that things need to change, so if we look at the wider mutual network of care across the borough, at the moment our falls prevention services are funded by the council and operate separately from the paramedic service and their highest rate of conveyance into the hospital is for falls which operates separately from the geriatric medical service which is responding to the needs of those patients together with the orthopaedic service when they present at hospital, which is organised separately from the therapy services that are then rehabilitating the patients back at home.
Our view is that actually, and this came out of a conference for us that David actually chaired about a year ago, is that all of those services actually should be together, they should be working as one team because their ultimate objective is the same, which is to enable people to… actually there should be a prevention agenda around keeping people in their home and preventing those falls happening in the first place.
But at the moment all those services are fragmented and independent. The only way we believe we can achieve a real integration and better outcomes for our population is if we put the right services together that should be working to the same shared objective. That’s just one example of the kind of area we’re trying to work on. Within that system as well, one of the other challenges that we face is that we have a population based system which is reliant on the person registered with the practice but we don’t have enough GPs. And that situation isn’t going to change. So we can't have a system which is based on relying on a GP as the first port of call. Increasingly we’re going to need to have a system which has a range of services working with the practice that provides that front end and in effect we see it as the GP taking more of a coordination or leadership role within that group. But we need a different kind of primary care for the future which has a wide range of different services working in and with the practice.
Part of our model where this first started is to put together multi-disciplinary teams in every single practice and that’s operating in Dudley now, has been for some time and we’re building on that all the time brining in new professions to form part of those multi-disciplinary teams.
The key factor to it is that what we’ve done is we’ve re-structured the services so that each member of staff is working together in that team, they’re working for the same population. It’s very very simple, but the reason why it works is because before each service was organised on its own professional basis and they worked with the population independently. By having every service working on the same population basis it means that team of people can genuinely start to work as a team and they can start to share skills across the different professions.
So picking up on what Suzanne was saying earlier about how do you get the best out of individual professions? Round that multi-disciplinary team each individual has their own unique skills, they’re also now understanding the skills that the others have to offer and they’re also sharing skills between them and learning from each other. This operates in practice, teams have regular meetings, but in actuality the way it really works is because they now work for the same population, all of those different professionals now know each other, the team is more important now and the organisation that they’re part of. So if one member of staff has an issue with a patient they know who else in the team they can call upon, whereas in the past they wouldn’t have been able to do that.
So it’s basically very simple, our concept is team without walls and what we’re looking at is how we bring teams together so that people can genuinely start to work together to share objectives. And the feedback we’re having from the staff involved in that is that they are massively more empowered now than they were before because they’re more efficient, they can work more effectively together and that’s because they can genuinely work together and they can learn from each other and they can share responsibility in terms of who takes the lead for individual patients.
We’re also, I think more interestingly, getting really positive feedback from the public but they don’t talk about it in terms of we’re getting a better healthcare treatment. The language that they use is more about quality of life and quality of experience. So it’s also starting to change our definition when we talk about outcome objective, what’s the real outcome objectives in this? A lot of the outcome objectives are more geared towards, from the patients’ point of view about quality of life, reducing social isolation, being better connected back into their community of which this approach helps people to address.
It’s not just as simple as putting teams together though. When we look at our model of care in the community there are basically three key themes that the population are asking us for. The first one is good access to services, the majority of our population, about 80% don’t actually have a serious problem, aren’t living with a long term condition or have a serious problem so when they do have an issue they want access to diagnostics and treatment, and increasingly we’re looking at how we can open access up to services in the community. But 20% of our population are living with at least one long term condition, they want better continuity of care, and then within that 20% an increasing cohort of that population presenting with multiple complex conditions with multiple needs.
In terms of how we’re developing the scope of the model, and we’re adding to this and learning on this all of the time, so just to give you some examples of the kind of things that we’re starting to work on, is that our pharmacists are working beyond simply medicines optimisation in practices, they’re contributing to long term condition reviews, they’re contributing to discharge planning, they’ve been supporting our practices on the diagnosis of hypertension to the point at which we now have the highest rate of diagnosis against prevalence in the country. So they’re broadening their skill set beyond simply looking at medicines and reviews.
Similarly we’re now working with our paramedics and the local ambulance services, linking into the multi-disciplinary teams, they’re bringing their top 10% frequent flyers into the multi-disciplinary team meetings to discuss how we can find different responses. And as a result of that different services are coming up with solutions which are reducing their utilisation and we’ve seen the frequency of 999 calls for high users drop as a consequence of that joined up approach. And we’re now involving the fire service because I didn’t know this until fairly recently, but there’s a fire prevention officer in every single ward, so we’re now using them to connect into the MDTs they’re getting referrals from the multi-disciplinary teams, so when they go into vulnerable peoples’ homes they’re not just doing a fire assessment but look at wider issues as well.
I think our local orthopaedic assessment service is a really good example of where the professional service themselves are developing their skills base beyond the original intention of what we commissioned from them. So last time I visited them which was a little while ago now but I was quite surprised that they were training themselves in CBT to help them manage the psychological impact of pain and better understand the nature of the patients who were presenting to them. It was kind of a no brainer once they explained it to me. It hadn’t even occurred to be before to talk to them about it.
With physiotherapy we now have physiotherapy operating out in 18 locations across the borough, we have direct access from all our practices, but we’re looking at now turning that on its head and saying actually what happens if we create open access to physio so that the port of calls is to the physio first before the practice because actually it should be a more cost efficient way of providing a service.
And I think probably the most impactful change that we’ve introduced recently is the involvement of the voluntary sector in our MDT’s because what they’re doing is changing our perspective on the culture and behaviour and the way that we should be working. Because their involvement is helping us to look at the whole of a person’s life, they’re not just assessing the individual based on a particular need. And what that’s starting to do is help build a different culture of working with our teams, which goes beyond simply health and starts to look at how we connect people back into their community. And actually that’s delivering more results than any other change we’ve implemented so far because by being better connected into their community reducing social isolation their actual use of health care is reducing as a result.
So in conclusion the key aspects I think of our model of care is an empowerment model, it’s about how do we get teams of people to work together? We’re looking at which services need to be connected together because they have a shared outcome objective. And what we’re finding is that actually the staff themselves are the strongest advocates for the model because once they’re able to more effectively work together they’re working out how to make the changes for themselves, they’re coming up with the solutions to us.
It provides staff with their permission to find solutions together but also to go beyond their traditional roles and start working outside their existing boundaries. And the size of the change that we’re potentially looking at here is that at the moment, if you go back to the organisational structures about 10% of our expenditure is on primary care but our expectation is that once we actually get services completely working together in a shared way across the system that we would expect about 70% of the services in the system to be working in this way. That requires our organisations to put aside their organisational form if you like, their organisation objectives and prioritise population need. That’s a very difficult thing for our organisations to do but the way in which it’s really working, and a way in which we’re getting there is by having the frontline staff presenting the solutions to us and saying, actually this is the way they want to work.