The document discusses unleashing dynamism in healthcare through integrated care. It describes Trafford's principles of integrated care, which focus on general practice as the locus of integration and involving social care. Clinical panels are discussed as a way to build relationships between primary and secondary care clinicians around patient care. Shared information and risk stratification of patients are presented as ways to support integrated care. Program management, communication, and addressing unscheduled care are also discussed as important elements of unleashing dynamism.

1. Unleashing D
U l hi Dynamismi
A Case Study:The Trafford Story of
Integrated Care
Presented by:
Samantha Nicol
Integrated Care System Programme Director
Dr Nigel Guest
General Practitioner
Nuffield Summit March 2011

2. Unleashing Dynamism
• Intensity
• Enthusiasm } qualities that enable people
to get things done
• Motivation
• Work systems
• Language } dimensions of organisational dynamism
• Interpersonal style
p y
• Modes of thinking
• Mindsets
• incentives – leadership – information - policy

3. Let s
Let’s see what you think?
• For just 5 minutes discuss what you think
unleashes dynamism in the programmes,
strategies and projects you are currently working
on
• Feedback – create a list

4. In the beginning……
beginning

5. Then there was
was……
 50 years of change
 FHSA
 Community T t
C it Trust
 Foundation Trust
 Hospital Trust
 Area District Strategic Health Authority

6. And so we arrive at 2008 – intolerable
condition
diti

7. What have been your intolerable
conditions
diti
• For just a couple of minutes think what your
intolerable conditions have been that have
prompted you to look to unleash dynamism
• Feedback – common themes?

8. And one man

9. And another man

10. Intermountain Healthcare Utah,
Utah 1975
 Perceived strengths of Intermountain
 Pioneering use of electronic medical records: ‘data-driven approach’
 Measure, track and thereby improve clinical outcomes
 Evidence-based medical care guidelines
 Preventative medicine
 Risk-stratification of the patient population
p p p
 Balance between needs of the community and available resources
 Non-profit health care delivery
Intermountain’s integrated system:
–ffrequently cited b the Obama administration as the prime exampl of a high-
tl it d by th Ob d i i t ti th i le f hi h
performing organisation that reduces healthcare costs

11. And then a few more men

12. It s
It’s also about

13. Unleashing dynamism through
VISIONARY LEADERSHIP
• That is:
– Vision
– Environment
– Relationships
– Power
– Performance
– Self
– Communication
– System and processes

14. Unleashing Dynamism through
RELATIONSHIPS
• Manipulating the environment through team spirit
p g g p
• Removing hierarchy, value individuals in their
own right
• Emphasis on the team finding the solution
• Focus on points of connection building trust and
rapportt
• Giving power to others – asking people what
they think coaching conversations
think,

15. Then lot’s more men and a few women
lot s

16. Principles
• Clinical Congress 2008
• Principles
• Scope of design

17. Trafford s
Trafford’s principles of integrated care
• Principle one: General Practice should be ‘locus of integration
• Principle Two: Consultant opinion is an essential component of
effective integrated services
• Principle Three: The delivery of integrated services will primarily
rest on extended role nursing and allied health professionals
• Principle Four: Integrated services will be enhanced by the
p g y
involvement of social care
• Principle Five: The voluntary sector and carers need a strong voice
in the design and delivery of services
• Principle Six: Future integrated services would bring together the
full range of primary care
• Principle Seven: Unscheduled care should be simple to access
and fully integrated
• Principle Eight: Where benefits can be derived from co-operation
between integrated care services and conventional acute hospital
services we will secure them

18. C eate the s o (1)
Create t e Vision ( )
The present
PCT THT/UHST/CMMC
Community Inpatient,
Inpatient
Non-PbR
Non PbR
services daycase,
services specialist
Outpatients
and
(Independent) diagnostics
GP1 GP3 GPn
… and we have persistent issues of poor
GP2 GP4
integration, resilience and perhaps quality…
is there a structural problem?

19. Systematic exploration of SPMS/ alternative
extended primary care provider (2)
t d d i id
The future?
PCT SPMS practice: GPs and THT/UHST/CMMC
consultants as partners
Community Inpatient,
Inpatient
Non-PbR
Non PbR
services daycase,
services specialist
Integrated Care Record Outpatients
and
(Independent) diagnostics
GP1 GP3 GPn
GP2 GP4
Or FT for THT

20. Systematic exploration of SPMS/ alternative
extended primary care provider (1)
t d d i id
The present

21. Unleashing Dynamism through
FOUNDATIONS
• In order to support the unleashing of dynamism you have
to have rules of engagement and foundations on which
you can build on
• People have to know what they are getting involved in
and what direction they are going in
• This helps them to know what resources they can offer
and what power th h
d h t they have t exchange
to h
• The vision inspired and created passion and enthusiasm,
its development involved p p from the start
p people

22. But that is not enough…
enough
• Between 2008 and 2010 there was a series of
business cases, submitted t th St t i
b i b itt d to the Strategic
Health Authority and PCT for funding to support
these leaders and the relationships to develop
the vision and implement the principles across
Trafford to develop an integrated care system
p g y
and an integrated care organisation through
which integrated services could be delivered.

23. It is probably NOT about permission
and f di
d funding
• Two business cases, very detailed and developed with
, y p
the help of external consultancy did not achieve their
required outcomes
• Alth
Although th did raise th awareness about th vision
h they i the b t the i i
and the potential of that vision to achieve dramatic
change to the way services are provided and their cost
• But their proposals were probably just too big and risky

24. You have done all that…..
• What else is there??

25. Unleashing Dynamism through
TESTING - ‘P f of Concept’
‘Proof f C t’
• What they did do however, was achieve a £2m
investment and a year to develop the
infrastructure necessary to deliver the vision
• It came back to
– Leadership
– Relationships
– Framework

26. In Action
• The following slides set out a series of case
g
studies taken from Trafford’s Integrated Care
System Programme that has now been running
for nearly one year
• Highlighting the elements of unleashed
dynamism across multi professional groups
groups,
multi organisations and during one of the most
turbulent times in the NHS in 60 years

27. Context
• Put in programme
p g
structure

28. Then Came
AWWoman!!
!!

29. Unleashing Dynamism through
PROGRAMME MANAGEMENT
OG G
• As a vehicle for implementing strategy and for bringing about corporate
renewal as alternative organising structure
• Programme as an emergent phenomenon, conscious of and responsive to
external change and shifting strategic goals
• Framework/structure therefore atemporal or with indeterminate time
horizons
• Vehicle for enhancing corporate vitality concerned with nurturing of
individual and organisation-wide capabilities as well as the efficient
deployment of resources
d l t f
• Intimately bound up with and determined by context rather than governed
by a common set of transferable principles and processes.
• Not a scaled up version of project management
• Adaptive not prescriptive

30. Unleashing Dynamism through
PROGRAMME MANAGEMENT
• Leadership at all levels, skilled individuals with clearly defined authority,
accountability and responsibility and programme governance aligned to sources of
influence
• Benefits management – identification, quantification, owners and tracking
• Stakeholder management and communications – understanding stakeholders
interests and impact of the programme, engagement of them
g g g
• Risk management and issue resolution – managing risk at an acceptable level
• Planning and control – prioritisation of projects and grouping of projects linked to
benefits realisation
• Business case management – value management of benefits, costs, timescales and
risks
• Quality management – configuration management, change control on documentation,
quality assurance and review of outputs to ensure they are ‘fit for purpose’

31. Unleashing Dynamism through
PROGRAMME MANAGEMENT
• Engaging people as change agents
• Realistic about the effort of change
• Link between behaviour and outcomes
• Priority to systems that provide touch points with
individuals and teams
• Used to provide space for the conversations
• Seeing culture as embedded in actions

32. Clinical Panel
Project Manager’s
• Louise Rogerson – End of Life
• Andrew Giles – Respiratory
p y
• Brooks Kenny – Diabetes
• Guy Hamilton – Data Sharing / Information
• Ric Taylor – Mental Health
• Tim Weedall – ENT
• Jason Hughes – Unscheduled Care

33. Andrew Giles
Respiratory Project Manager
Gail Mann
ICS Programme Manager

34. Diabetes Clinical Panel
• Put in picture of Panel

35. Unleashing Dynamism through
CLINICAL PANELS
• A safe shared space to build relationships that are about
clinical care not about organisations
li i l t b t i ti
• Chaired by a primary and secondary care clinician
• A good mix of opinions, but essentially commonly shared
g p y y
and owned values
• Patients and carers
• Clear strategic outcomes – focussing on quality of
clinical care and clinical outcomes measuring
improvement
• Time

36. Unleashing Dynamism through
CLINICAL PANELS
• Management support
g pp
• Information/data – about their current patients
and clinical practice
• Shared aims
• Small steps
• [Any chance we could do this like a jigsaw
coming together with previous slide and make it
one slide?]

37. Unleashing Dynamism through SHARED INFORMATION
Illustration 1 – risk stratification (diabetes)
Band1 Band2 Band3 Band4 Band5
Biochemical
HbA1c <7 7‐9 >9 don't know
HbA1c date
HbA1c date <13 months
<13 months >13months don t know
don't know
Systolic Blood pressure <120 120‐140 >140 don't know
Diastolic Blod pressure <70 70‐90 >90 don't know
Serum Cholesterol <5 >5 don't know
serum Creatinine (kidney) <120 120‐200 >200 don't know
Microalbinuria <3 >3 don't know
Microvascular comorbities
Chronic Kidney Disease 1 2 3 4 5
Diabetic Neuropathy
Diabetic Neuropathy yes No don t know
don't know
Retinopathy yes No don't know
Macrovascular comorbidities
MI (ACS/NSTEMI/STEMI/ANGINA) yes no
CVA (TIA/RIND/CVA) yes no
PVD yes no
Other
Age 18 44
18‐44 45 64
45‐64 65+
Hospital admissions in last 12m 1 2 or more

38. Unleashing Dynamism through SHARED
INFORMATION
Illustration 2 – i k t tifi ti (di b t )
Ill t ti 2 risk stratification (diabetes)
Band1 Band2 Band3 Band4 Band5
Biochemical
HbA1c <7 7‐9 >9 don't know
HbA1c date <13 months >13months don't know
Systolic Blood pressure <120 120‐140 >140 don't know
Diastolic Blod pressure <70 70‐90 >90 don't know
Serum Cholesterol <5 >5 don't know
serum Creatinine (kidney) <120 120‐200 >200 don't know
Microalbinuria <3
3 >3
3 don t know
don't know
Microvascular comorbities
Chronic Kidney Disease
Diabetic Neuropathy
1
yes
2
No
3
don't know
4 5 Risk
Retinopathy yes No don't know
Category
Macrovascular comorbidities
MI (ACS/NSTEMI/STEMI/ANGINA)
CVA (TIA/RIND/CVA)
yes
yes
no
no
1
PVD yes no
Other
Age 18‐44 45‐64 65+
Hospital admissions in last 12m 1 2 or more
Note: For illustration only
y

39. Advanced Training Programme

40. Unleashing Dynamism through
COMMUNICATION

41. In Summary
It is all about… It is not all about…..
A burning platform or an intolerable condition
Visionary Leadership at all levels Seeking permission
Relationships – cross organisational and professional boundaries Funding
Foundations – vision, values Organisations
Programme Management – providing a framework to support creativity and Bricks and Mortar
innovation while ensuring shared learning, transparency of benefits and
accountability
Command and control

42. UNSCHEDULED CARE

43. I leave you with this thought
thought….
• Matthew chapter 4 verses 12 -23
p
– A fisher of men a leader calling to his followers caught through
teaching and persuasion
– Together grasp the sense of what is needed to be done
– Build on what has been done well in the past
– Called to serve
• Vision, energy, enthusiasm
– Hearts turned by
• Hands willing to get dirty
• Working together to deliver a vision.