Quality improvement: learning from innovations in the vanguards

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I have recently returned from an exciting, whirlwind tour of another set of new care models sites. This was my fourth such tour. My goal for these visits, which I make as an International Visiting Fellow for The King’s Fund, is to attempt to understand what the vanguard organisations are trying to do, how well they are faring, and how they might progress even better and faster. On this trip, the additional question was: ‘How can these lessons and models be spread more widely across the NHS?’

Let me recount a few of the many highlights, and then summarise some general conclusions about the new care models investment.

My trip began in Better Care Together (Morecambe Bay Health Community), but not at a health care facility. Instead, I found myself at the Westgate Primary School, being escorted by a committee of six 10-year-old children. They explained to me that they were participants in the school’s programme to encourage pupils to run one mile every day – six laps around the school yard – in almost any weather. The teachers ran too. The children reported increased alertness, better sleep patterns, and having fun. Every single child at Westgate Primary does the same, every day.

The programme had been brought to the school by a Morecambe Bay GP, Dr Andy Knox, who – with the support of his clinical commissioning group (CCG) – is devoting two days a week to helping improve health and wellbeing in schools. He has adapted the ‘Daily Mile’ programme used by St Ninian’s Primary School in Stirling, Scotland, which has just about eliminated obesity in its lower primary grades. As of now, 2,000 children in Morecambe Bay are running a mile a day, and 3,000 more from around Lancashire will be doing the same within the year. The likely result: massive reductions in diabetes and other complications of being overweight within this generation. Dr Knox is setting his sights on family and school nutrition next.

A few miles away at Lancaster Royal Infirmary, GP Dr George Dingle introduced me to the ‘Advice and Guidance’ programme. With the full support of the hospital’s chief executive, Jackie Daniel, and the local GP community, this is linking more than 300 GPs and consultants across 17 specialties in a rapid, internet-based review of patients who could be referred. This has resulted in a decrease in actual referrals by more than 30 per cent, with more satisfaction for GPs, consultants and patients. More than 4,500 such consultations occurred in the past 12 months.

A trip to Leeds followed, and a meeting with six vanguards to hear about the work from Wellbeing Erewash, where GP Dr Duncan Gooch and CCG head Rakesh Marwaha are pioneering a new ‘GP-lite’ primary care model focused on patient-led goals, home-based care, multidisciplinary teamwork with community organisations, and anticipatory interventions – all aimed at keeping people in their homes and functioning at their best possible level. They are engaging all 12 GP practices – more than 60 GPs – in Erewash, and are beginning to teach clinicians in other Derbyshire sites about their new model.

Two care home vanguards – Connecting Care – Wakefield District and Sutton Homes of Care – were also on my itinerary, and I saw first-hand extraordinary degrees of co-operation among staff in care homes, GP practices, hospitals, community nursing, and ambulance services to assure that residents’ problems were intercepted long before hospitalisation was needed, and that hospital stays were as short as possible. Sutton is using the ‘Red Bag’ innovation – a pre-packaged collection of supplies and records that accompany every patient to hospital. The Red Bag pathway appears to have reduced average hospital length of stay by four days. More than 98 care homes in Wakefield and 80 care homes in Sutton are engaged in these programmes of work.

I could go on. One site after another with energised clinicians, managers and staff, creating and testing new ways to achieve better care, better health, and lower cost through improvement – with a sense of buoyancy and pride frankly at a low ebb in much of the NHS at this stressful time. And the grassroots leadership by GPs, nurses, frontline managers and others is palpable. The NHS five year forward view presents a top-down vision, and this is real bottom-up movement towards that vision.

In my view, the new care models investment is paying off in results; not everywhere and largely still in local settings, but well enough to offer hope that redesign and improvement can offer the NHS a route to an entirely new level of performance.

To achieve that, the next (and essential) step must be to ‘spread’ and ‘scale-up’ these initiatives, not just in the vanguards but across the NHS. I put these terms in inverted commas because ‘spread’ and ‘scale-up’ are not linear. They cannot be mandated, installed, or ordered up. For complex changes in complex systems, adopting someone else’s innovations is not like plugging in a toaster; rather it is like learning to speak Spanish or play a piano. Experts, pioneers, coaches – they can all help, but the successes of Morecambe Bay, Erewash, Wakefield and Sutton will need to be studied, adapted, tried out and refined site by site, with local leaders just like Andy Knox and Duncan Gooch carrying the flag. That will take time, encouragement, and tolerance for the awkward phases of learning.

I can see the potential pay-off: massive. The challenge and the discipline for the senior ranks of the NHS and the government will be to trust the people of the NHS, give them the tools for learning, and offer the time and space to draw the lessons they can from the pioneering vanguard sites.

Comments

patrick gardner

Comment date
27 January 2017
There is no chance of these admirable innovations scaling up if scalability requires the equivalent of learning Spanish or how to play the piano.

Richard Simpson

Position
Professor health Sciences and Sport,
Organisation
University of Stirling
Comment date
29 January 2017
Last year before I retired as an MSP and shadow Public Health Minister I visited St Ninians Primary and saw for myself the effects of the 'Daily Mile' the only two overweight children I saw in the two classes who were running were, I was told, recent transfers to the school. I saw one child hop round the designated path.. when I asked him why he was hopping he said he had a sore foot but didn't want to be left out. Two pals stayed with him running more on the spot. The sense of fun was palpable the level of chatter high. Stirling council has rolled the programme out to all primaries and has also received awards for its school meals programme All meals are free for primary one to three to promote good nutrition.

Dr Malcolm Rigler

Position
NHS GP and Health Ambassador The Patients Association,
Organisation
Project H.A.L at : www.librariesandhealth.com
Comment date
29 January 2017
What a great idea for Don to actually visit some local GP led projects attempting to promote "Health and Well Being" . Over the past 40 years I have been aware of a number of GPs who have tried various innovations to promote Health such as the late Dr John James in Bristol , Dr Angela Lennox , Dr Bob Gilbertson in Christchurch , Dr Derek Browne in the New Forest and many others. Sadly the Faculty of Public Health , the Royal College of General Practitioners , NHS Senior Managers and our Political Leaders have all turned a blind eye to these important "green shoots" so that many of the protagonists have lost heart , retired or died without any real acknowledgement of their pioneering efforts. It would be good if Don Berwick could bring together the stories behind these great pioneers within Primary Care and do something to make sure that potential new recruits to the GP workforce get to hear about these pioneering GPs and are offered "progression routes" within General Medical Practice so that they too can combine personal medical care with the creation of projects and programmes that might be called "preventative medicine strategies". In fact I think that the survival of NHS GP practice in the UK depends upon
such an initiative. Dr Malcolm Rigler GP and FRSPH

Alison Baker

Position
Patient/carer,
Comment date
29 January 2017
There are well tried and tested methods of learning Spanish or how to play the piano and they do not involve dozens of committee meetings. Of course local people need to be convinced these innovations are worthwhile but, that said, dissemination might be a lot quicker if it was based on the assumption that these new approaches WILL basically work in other settings and only need tweaking if there are genuine contextual differences. The original innovators will also no doubt have come up with solutions to problems which could be transferred rather than each site starting from a blank sheet.

Helen Caton-Hughes

Position
MD,
Organisation
The Forton Group Ltd
Comment date
30 January 2017
I'm learning Italian at the moment and it just requires that I apply myself each day. Same with my exercise. What's common to all of my habits is the commitment to start. Just start. Then do it. Then notice the benefits. Then do some more. Now, easier said than done in the complex Vanguard environment. What I do know is the high level of investment in better relationships put in by one of these schemes - to make sure that the initial commitment is in place. Call it 'buy-in'; get a 'champion' - what you will - just make sure there's real support from enthusiasts and do-ers - not just talkers.

Rachel Wilkinson

Position
Healthcare Institutional Account Manager,
Organisation
Wiley
Comment date
31 January 2017
This is what its all about, new ideas, new forward ways of thinking and people showing passion and support to help save our NHS.

Richard Davis

Position
Consultant,
Organisation
Independent
Comment date
16 February 2017
Complex changes in complex systems, yes, and hugely important that they can be nurtured. The cultural elements that I think need developing to allow that to happen are these:

Financial literacy - the ability to use finance as a tool not a driver

Welcome of criticism and confidence to engage with politicians and Press

A sense of responsibility for the system as whole

I would love to be part of this vital endeavour

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