Southwark and Lambeth-based projects Knee High Design Challenge, Diabetes Modernisation Initiative and Pathway explore what it takes to maintain change in the local healthcare system: understanding the issue & adapting to ever-changing context; gathering & maximising evidence; and building & maintaining meaningful relationships. Find out more at www.gsttcharity.org.uk

1. Sustaining change in healthcare:
learning from local successes
6 May 2015

2. Sustaining Change in Healthcare
Getting under the skin of the problem and
remaining relevant to local context
in the Knee High Design Challenge
Mat Hunter
Chief Design Officer, Design Council

3. Pop up parks

4. Creative Homes

5. Kids Connect

6. Framing the
challenge
1

7. Double Diamond

8. Ethnographic
research

10. Convening diverse
talent
2

13. Supporting trial
and error
3

15. Staged Investment

16. In summary:
1. Framing the challenge
2. Convening diverse talent
3. Supporting trial and error

17. Thank You

18. Sustaining change in healthcare:
learning from local successes
6 May 2015

19. Sustaining change
Jane Stopher
www.dmi-diabetes.org.uk

20. June 2014 20
Our vision was for Lambeth and Southwark to be two of
the best boroughs to live well with diabetes…
• Strategic Priorities: Children, Primary Care, Community Care and Self-
management
• Ambitious aims to deliver sustainable improved outcomes at a population
level
• Strong cross organisation partnership with commissioners, providers and
service-users
• Scaleable, not increase costs, clinically led and focus on what mattered to
patients (Triple Aim Principles)
• Business case built on early detection, better biological control and self
management preventing/ delaying high cost complications
• Scaleability and sustainability key design principles from the outset

21. June 2014 21
Measurement as legacy
• Lambeth and Southwark and the
DMI cited as a London exemplar in
London’s Blood Sugar Rush report,
2013
• Quality in Care winners for “Best
CCG initiative” and “Best Cross-
organisational partnership” 2014
• Chair of Voluntary Group, highly
commended, NHS Participant of
the year, 2014
• The Commonwealth Fund, case
study 2014
• IHI presentation, 2015: “Achieving
triple aim in inner London”
• External economic evaluation
(OPM)
• Direct reductions in service
delivery and indirect benefits
from long term health
improvements.
• In total, savings are expected:
• £1.34m in year 1 (ranging from
£933k to £1.68m).
• £10.10m over the next 5 years
(ranging from £5.54m to
£14.13m) and
• £29.38m over 10 years
(ranging from £12.25m to
£45.40m).

22. June 2014 22
How do you measure a system of excellence?

23. June 2014 23
Focus the system on population health:
• The combined register size has grown by 23% since 2009/10; 16.6% since 2010/11.
• While growth over the past year slowed to 3% (compared with 9% the year before),
this still represents around 800 additional patients on the registers.
Lambeth
Southwark
10,000
11,000
12,000
13,000
14,000
15,000
16,000
2009/10 2010/11 2011/12 2012/13 2013/14
Lambethand Southwark diabetes patient registers
2009/10 to2013/14

24. June 2014 24
Focus the system on flow through care settings: Specialist
diabetes care in the community
0
50
100
150
200
250
300
350
Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4
2011/12 2012/13 2013/14
Outpatients: GP-initiated 1st attendances
LambethCCG
Southwark CCG
0
20
40
60
80
100
120
140
160
180
200
Qtr4
Qtr1
Qtr2
Qtr3
Qtr4
Qtr1
Qtr2
Qtr3
Qtr4
Qtr1
Qtr2
Qtr3
Qtr4
Qtr1
Qtr2
Qtr3
Qtr4
2010/11 2011/12 2012/13 2013/14
Numberofemergencyadmissions
Emergency Admissions - Primary Diagnosis: Diabetes
Lambeth &Southwark registered patients
GSTT & KING'S

25. June 2014 25
Self-management as a system change

26. June 2014 26
Setting Minimum Standards for care
planning enabled routine adoption
• 2013/14 data are numbers of care plans coded with GP systems
• Assessment of quality is included in Southwark CCG scheme in 2014/15
• Care planning advocates quality assure in eye screening services
17%
39%
0% 10% 20% 30% 40% 50%
Lambeth&
Southwark
combined
% of people on diabetes registerswith a
collaborative care plan
2013/14
2012/13

27. June 2014 27
2011/12 2013/14 Change Annual
DMI 719.0 1294.8 80.1% 40.0%
Lambeth 418.0 829.2 98.4% 49.2%
2010/11 2013/14 Change Annual
Southwark 266.0 465.6 75.0% 25.0%
0
200
400
600
800
1000
1200
1400
2010/11 2011/12 2012/13 2013/14
AnnualAttendances
Attendances at structured education
DMI Lambeth Southwark
Attendances at
structured education:
the number of patients
attending structured
education, note for
Lambeth this includes
DESMOND and
alternative courses.
Source: Local DMI data
No comparator
Systematically offer people education on diagnosis

28. June 2014 28
Support primary care to deliver best practice

29. June 2014 29
60%
65%
70%
75%
80%
2010/11 2011/12 2012/13 2013/14
Percentageofpeopleondiabetes
register(aged17+)
HbA1c ≤ 64mmol/mol
DMI ONS group Blue group London England
ONS group: Brent, City &
Hackney, Haringey, Lewisham,
Newham
Blue group: Barnet, Camden,
Croydon, Enfield, Greenwich,
Hammersmith & Fulham, Haringey,
Hillingdon, Islington, Kensington &
Chelsea, Kingston, Lewisham,
Richmond, Sutton & Merton,
Waltham Forest, Wandsworth,
Westminster
Source: National data – QOF
2010/11 2012/13 Change Annual
DMI 67.3% 67.8% 0.7% 0.3%
ONS group 67.0% 65.1% -2.8% -1.4%
Blue group 68.9% 66.0% -4.1% -2.1%
London 68.5% 66.3% -3.2% -1.6%
England 70.5% 68.5% -2.8% -1.4%
Better glucose control for over 5,500 people

30. June 2014 30
Healthy blood pressure control for over 6000
people
60%
65%
70%
75%
80%
2010/11 2011/12 2012/13 2013/14
Percentageofpeopleondiabetes
register(aged17+)
Blood pressure ≤ 140/80
DMI ONS group Blue group London England
ONS group: Brent, City &
Hackney, Haringey, Lewisham,
Newham
Blue group: Barnet, Camden,
Croydon, Enfield, Greenwich,
Hammersmith & Fulham, Haringey,
Hillingdon, Islington, Kensington &
Chelsea, Kingston, Lewisham,
Richmond, Sutton & Merton,
Waltham Forest, Wandsworth,
Westminster
Source: National data – QOF
2011/12 2012/13 Change Annual
DMI 61.8% 66.4% 7.5% 7.5%
ONS group 64.6% 66.2% 2.4% 2.4%
Blue group 63.1% 65.3% 3.6% 3.6%
London 64.0% 66.3% 3.6% 3.6%
England 65.2% 67.2% 3.0% 3.0%

31. June 2014 31
• 3,951 more people with diabetes received all 9 care processes in 2013/14
• Greatest improvements in ACR, foot checks and smoking status
Big improvements in people receiving all
Nine Care Processes in primary care
31.53%
45.50%
34%
47.71%
0% 10% 20% 30% 40% 50% 60%
2012/13
2013/14
Percentage of diabetes register receiving all 9 care processes
Southwark Lambeth

32. June 2014 32
Learnings
• Measurement tells the story of change and helps the
“flame shine bright”- macro, meso and micro levels
• Creates shared purpose and ambition, and a route map
• System measures shine light into the shadows and
across our “borders”
• User led measures truly test the process or experience
• Draw on multiple expertise and methodology
• Accept the data isn’t perfect

33. Sustaining change in healthcare:
learning from local successes
6 May 2015

34. Sustainability – establishing and
maintaining the right relationships
Dr Nigel Hewett
Medical Director Pathway

38. Hewett et al. A general practitioner and nurse led
approach to improving hospital care for homeless people
BMJ 2012;345:e5999

41. Establishing Relationships
• Needs assessment – gathered data and
opinions from all stakeholders in hospitals and
community, especially service users
• Steering group for needs assessment became
steering group for the project – key clinical
managers from the 3 Trusts, KHP and Lambeth
CCG (commissioners)

42. Maintaining Relationships
• Continuous process of progress reports,
launch events, annual reports
• Data and outcomes presented in a way which
chimes with current drivers for the particular
audience

43. Homeless people attend A&E 5 times
as much, are admitted 3 times as
often, and stay 3 times as long as the
general public. Overall they cost 8
times as much.1
The average age of death for homeless
people is just 47 years.2
Why target homeless people?

44. • Marmot review –
‘proportionate universalism’
• Public Health Outcomes
Framework
• Health and Social Care Act 2012
and the policy reasons…

45. • Tri-morbidity
• Lack of follow-up care
 Lack of local connection and/or
lack of appropriate
accommodation options
 Chaos in the client group
Why the poor outcomes….?

46. The ‘Pathway’ approach
Bed days reduced by 30%... and
a better patient experience

47. How was this achieved?
• Maximising the benefit of
admissions
• Expert and sensitive support
team with specific skill sets
• Team fully linked in to homeless
community services
• Delayed discharges

48. Homeless attendance data 2011
A&E
attendances
Hospital
admissions
Cost
GSTT 4923 1379 £5,623,810
KCH 718 240 £947,289
SLAM 148 £2,670,553

49. Page 49
A pilot service involving 13 staff
•Multi-agency…

50. Page 50
A new pathway for homeless patients
• Attending St
Thomas’,Guy’s or
King’s
Homeless
person
• GSTT base:
GP 0.4 wte; RN 2 wte;
OT 1wte; HSW 3 wte;
Admin 1wte
• KCH base:
GP 0.4 wte; MHP 1
wte; SW 0.4wte; HSW
1 wte
KHP
Pathway
Homeless
Team
• Practical assistance
• Health review
• Housing
• Reconnections
• Frequent attender work
• Safeguarding
Integrated,
multi-professional
assistance
•Outreach
teams
•Day centres
•Homeless
health teams
•GP practices
Community
support
• Peer advocate
support with
physical health
appointments
and GP
registration
Groundswell

51. Page 51
What do we do?
• Practical assistance
• Comprehensive health reviews
• Linking in with community services
• Help to find housing
• Reconnection work
• Frequent attender casework
• Safeguarding of vulnerable adults
• Tap-dancing, juggling, stand-up…

52. Maintaining Relationships
• “Integration”, “KHP”, “Mental and Physical
Health”, “Health Inequalities”, “Value”,
“Efficiency” A&E frequent attenders etc etc.
• Encourage ownership by partners – share the
benefits – look at this fabulous thing you have
done!

53. Page 53
Data at 4 weeks
GSTT Kings
No of referrals 116
(109 people)
40
(39 people)
% on CHAIN 75% 22%
Key referral routes 39% from A&E
22 wards
Community
25% from
A&E
19 wards
Community

54. Page 54
Data at 4 weeks
GSTT Kings
% seen / casework
undertaken
93% 82%
% improved
housing status at
discharge
28.5% 32.5%
Reconnections 8 1
Feedback
questionnaires
19 returned –
16 ‘excellent’,
3 ‘good’
1 returned –
‘excellent’

55. Page 55
Borough links on discharge
GSTT Kings
Westminster 18.9% -
Lambeth 15.8% 18.1%
Southwark 13.1% 27.5%
Lewisham 3.7% 9%
Other London 14.9% 12.1%
Outside London 19.6% -
Unknown 14% 33.3%

56. Case Studies – tell the stories
Page 56

57. Thank you

58. Sustaining change in healthcare:
learning from local successes
6 May 2015