Care models in action – 12 months in and learning from failure

The national new care models programme brings together local health and care systems as vanguards to radically redesign care for the local populations they serve. Professor Don Berwick was appointed in 2015 to support the vanguards learn from international best practice and visited the UK recently to see how they are progressing. Two vanguards, Fylde Coast (@YCOPFyldeCoast) and Better Local Care (Hampshire) (@BetterLocalCare) presented their ‘story’ at a King’s Fund event and Peter Tinson and Dr Kate Fayers use this blog to discuss their approach. 

The Fylde Coast Local Health Economy vanguard care models story may be a familiar one.  It is one of two populations, one living in the seaside resort of Blackpool facing significant deprivation and very poor life expectancy and one in the surrounding countryside facing the problems associated with old age, including multiple long-term conditions.

Our story started with a detailed understanding of our population needs and how to use the resources that we have available as effectively and efficiently as possible. We then explored numerous international care models that shaped the development of our extensive care and enhanced primary care models.

Extensive care is aimed at people aged 60 and above who have two or more long-term conditions, such as diabetes or chronic heart problems. The service sees senior consultants, GPs, advanced practitioners, care coordinators, wellbeing support workers and other supporting staff all working together as part of one harmonised team. Patients are referred by their GP and meet with the team to undergo an initial assessment from which a care plan is developed with them. Each patient is allocated their own wellbeing support worker, who they meet with on a regular basis, to progress this care plan and achieve the small but personal goals they have set themselves. Crucially, the service provides a single point of access for patients.

Enhanced primary care is an increased level of clinical and social support provided in the local community through ‘neighbourhood care teams’. It sees nurses, care coordinators, therapists, wellbeing support workers and others working alongside local GPs to empower patients to self-care by learning more about their condition and how they can stay well for longer.

With support from the national new care models programme we went from concept to detailed design and implementation of our extensive care model in less than six months. Something we’ve never done at such scale and pace before.

Just over 12 months later and our extensive care model is now rolled out across the entire Fylde Coast. The community based service operates from four primary care centre ‘hubs’ serving all 10 of our neighbourhoods with every GP practice across the area able to refer eligible patients to receive the increased  support. We’ve also just begun the phased roll out of our enhanced primary care model. This will mean that those people who often require the most support will benefit from seamless care which is specifically tailored to their individual needs.

We’ve learnt a lot along the way, ranging from new system leadership behaviours to practical implementation lessons, such as the importance of ‘selling’ the service to patients and various day-to-day procedural aspects – with the reality being that these sorts of things can only really be learnt from testing this new way of working in the first place.

Perhaps more excitingly we now have over 12 months’ worth of ‘deflection’ or impact data that is making us rethink our approach to patient risk stratification and how we target the model more effectively.

It was great sharing some of these insights with vanguard and other colleagues at the recent ‘Fail fast and learn quickly’ event and particularly valuable hearing from vanguards with similar experiences. South Somerset Symphony Programme vanguard (@SymphonyProj), we will be in touch very soon!

I’d echo comments from other attendees, rather than failing and learning fast, we are testing and learning fast!

In a post vanguard environment, the challenge for our sustainability and transformation plans (STP) leaders is to both create an environment where we continue to test and learn and rapidly implement our collective learning.

Dr Kate Fayers

The other day a psychiatrist asked me if I was depressed. The benefit of working in an integrated community trust is the opportunity to work alongside specialist colleagues with a varied range of interests. As I extolled my sense of failure and frustration with different, apparently unconnected pieces of work, I explained that I don’t get depressed but that everything seemed a bit tough right now.

In the pub that evening, my medic friends confirmed that they too were undepressed. Same challenges, same frustrations. There seemed to be a lot of it about.

I didn’t know any psychiatrists until I took up my new consultant post in 2010. Moving out of secondary care was a revelation. My new post supports a brand new community diabetes service.

Truth be told, I had always questioned my registrar training in secondary care, but learned to keep those thoughts to myself. Success in training and clinical practice, as demonstrated by my senior colleagues, involved the preservation of the status quo, and occasionally, an audit.

The other week I found myself at The King’s Fund attending a workshop on failure – and how we can learn from it. Somehow, such a discussion seemed inevitable and the timing never more perfect. Bring a case study – the people from the new care models programme said. I needed no more encouragement.

What happened next, however, seemed to come from a pre-written destiny. In the morning Professor Don Berwick set a vision for failure as a celebrated component of success. Riding a bike successfully is nearly impossible without falling off. Careful calculated risk accelerates learning, as Professor Berwick demonstrated effortlessly.

His colleague Al Mulley (Director of the Dartmouth Centre for Health Care Delivery Science) contacted me 24 hours before we met to facilitate my case study. In the way that only true experts can, he directed me to a single page on a single document and in that moment has possibly changed the whole direction of my career.

In our workshop I described our local challenges in delivering innovative care models in our multispecialty community provider vanguard. I explained the unwritten norms that shape the delivery of specialist care and how we have tried making care more straightforward by changing culture and behaviours.

I explained how I had failed to deliver innovation despite a clear clinical consensus and my frustrations that I was unable to move things forward. Practical suggestions were made from the floor – how my leaders could unlock me and how, in turn, those leaders could be unlocked.  What I saw was a wealth of support and a network of people who get it.

And the paper I mentioned above? It was –Chris Trimble, Harvard Business Review,January 2011 ‘The CEO’s role in business model reinvention’, page 5. Day to day quality improvement and innovation are different. Simple as that. They sit in different boxes and need different attention by our leaders in order to plan for the future.

I am undepressed about failure … I am an innovator and I am looking forward to making a difference.

Kate Fayers

Dr Kate Fayers is a consultant diabetologist who leads Southern Health NHS Foundation Trust’s West Hampshire community diabetes service.

Kate is involved in the Better Local Care (Hampshire) vanguard, working with partners to ensure appropriate access to specialist diabetes care and to promote patient self-management.

Follow Kate on Twitter: @drkatefayers.

Peter Tinson

Chief Operating Officer NHS Fylde and Wyre Clinical Commissioning Group.

Peter has extensive commissioning experience across Lancashire and Merseyside and, prior to his appointment at the clinical commissioning group (CCG), was a CCG deputy chief officer. He has undertaken a wide range of senior commissioning roles across primary, community, secondary and tertiary services, including the successful negotiation of large and complex contracts, and the development of new primary and community service models and associated capital builds.

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  1. Phil Dourado says:

    Hmmm. Some bullet points like “The three main transferable points of learning may be …” would be key here. Both stories slip and slide a bit in terms of focus and outcome. Hopefully both stories are written up somewhere else with the transferable (or adaptable or possibly useful) learning for others highlighted, as this is ‘just’ a blog post rather than comprehensive learning transfer stories (I hope). You have to watch out for that Chris Trimble ‘Aha!’ moment from the HBR that small daily improvements are not innovation. There’s long been an argument between continuous small scale improvement of the Toyota kind and ‘big’ innovation like re-designing and implementing a system. A lot of people who study and work in innovation – including me – don’t agree that the two are always mutually exclusive. You can ‘tinker your way’ to a new way of doing things. And, the argument has turned in our direction in recent years. Read Peter Sims’ ‘Little Bets’ rather than a six year old HBR article.

  2. Kassander says:

    Sorry folks, these two essays tell me nothing of any substance.
    Not one example of “I explained how I had … ”
    Nor ” my leaders could unlock me and how, in turn, those leaders could be unlocked.” (50 Shades?)
    As for the Damascene conversion by the content of page 5 – all roads surfed were cul de sacs.This Saul remains a cynic.

  3. Patricia Elliott says:

    Some statistics would be helpful, and costs.