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Guest authors bring different perspectives and diverse voices to our blog. They do not always represent the views of The King’s Fund.


Lessons from Canterbury


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    Stephen Dunn

Three years ago Chris Ham came to Bury St Edmunds to discuss west Suffolk’s strategy for the future. I had just been appointed as chief executive of the West Suffolk NHS Foundation Trust, and at the time we were unclear whether we needed to evolve into a hospital chain or pursue a strategy of community integration.

The diagnosis then, as now, was that our problem was not quality or efficiency but our ability to effectively meet the rising demand of a largely ageing and affluent population. Chris urged us to take action and to learn the lessons of integration from around the world, particularly the experiences in Canterbury, New Zealand.

In this welcome update, Anna Charles builds on Nick Timmins and Chris Ham’s initial review of the experiences of Canterbury and reflects on the implications for new models of care and for sustainability and transformation partnerships. It is a must read for anyone developing models of community integration.

This report gives me hope for five reasons. First, because it is realistic. The Canterbury system has slowed the demand for acute care; it has not reversed it. We can’t bury our heads in the sand believing that we can reverse the rising tide of an ageing population with multiple long-term conditions. What is more, the transformation doesn’t happen overnight; it takes years of trust and hard slog. The NHS five year forward view might need a contract extension!

The experience from New Zealand also makes clear that we shouldn't divest away from acute hospitals but rather work differently in an alliance with health and care community and primary care services.

We are working to develop an alliance to run community services on a locality basis. We hope to partner with the county council, the GP federation and a mental health provider. This is a new form of contracting that parallels the Canterbury experience.

Second, the report emphasises the importance of shared goals and aligned incentives. In Canterbury they unified behind the ‘one system, one budget’ mantra. For the last couple of years we have had a block contract with West Suffolk Clinical Commissioning Group (CCG) with an agreed health and care vision that has been endorsed by our health and wellbeing board.

Sometimes our regulator wonders whether we are trying buy integration by putting ourselves on a block contract. But there is only a finite amount of money for our local population and we might as well work with the CCG and other local providers to make the Suffolk pound go that little bit further. This is a key lesson from Canterbury. And it would help if the regulators came to a common agreement on how to establish and police a one-system budget. I suspect this is coming.

Third, the report highlights the need to invest in leadership and in improvement science and new technologies across health and care. In Canterbury 80 senior staff participated in the Xceler8 programme, which embedded management techniques such as Lean and Six Sigma across the health economy. We are beginning to do something similar in west Suffolk. We have begun our first system leadership days and have a focus on becoming a health and care digital exemplar on the back of the successful launch of our new electronic patient record, e-Care.

Our objectives are to become (as far as possible) a paperless hospital, a paperless health and care system, to upgrade our hardware and to share our experiences with the NHS. This summer we have been connecting our e-Care system to primary care as well as getting our different electronic health systems to communicate with each other. This is only a start to sharing information and developing a population health focus. But it’s clear from Canterbury that this investment should pay dividends down the line.

Fourth, the report showcases new models of care, especially around community rehabilitation and enablement. In Canterbury, the community rehabilitation enablement and support team offers community-based rehab to older people to avoid admissions or get people home more quickly. The report seems to suggest that these teams are made up of nurses, occupational therapists and physios.

On the face of it I think we are going further. We have set up an early intervention team (EIT) which has nurses, occupational therapists and physios, social workers, third sector volunteers – eg Age UK– paramedics, and care workers. This is making a huge difference and helping us manage demand. This multidisciplinary focus on doing what is needed to get people back on their feet and in their homes or in their community has to be the way forward.

The experience of Canterbury also emphasises the importance of pathway experimentation. Together with partners across west Suffolk we are recruiting one of the country’s first Buurtzorg teams to test a Dutch model of integrated health and personal care.

Buurtzorg, which in English means ‘neighbourhood care’, advocates the use of highly qualified nurses to deliver dedicated personal and health care to patients in a neighbourhood. The nurses work in small, self-managed teams to deliver holistic care, working alongside their formal and informal networks to allow individuals to stay in their homes and communities for as long as possible.

In the Netherlands, the Buurtzorg model has led both to higher levels of satisfaction and significant reductions in the cost of care provision by providing early detection of problems, increasing quality of life, reducing longer term care needs and reducing hospital admissions.

To me, this report says the NHS five year forward view and what we are doing locally are the right sort of things. Aligned incentives, investing in leadership, new pathways and new technologies result in marginal improvements and marginal gains that will help slow the growth in the demand for health and care services. But, and this is my fifth takeaway, without strong relationships underpinned by trust, and strong staff engagement, none of this is possible.