Collaboration for Leadership in Applied Health Research and Care
for South Yorkshire (CLAHRC SY). www.clahrc-sy.nihr.ac.uk
Innovations in Commissioning;
developing a 'whole system' strategic
focus
Dr Sally Fowler Davis- Theme Lead
Dr Tony Smith
Dr Robin Lewis
Professor Malcolm Whitfield
Sheffield Hallam University CLAHRC South Yorkshire, Innovation in Commissioning Theme
CLAHRC
for South Yorkshire
So what?
• We wondered if it would be helpful to
present our learning with a view to further;
• NIHR proposals, especially related to service
models and service evaluation?
• Development of knowledge exchange and
transfer activity with Primary Care and general
practice?
• PPI engagement in research and health and
social care –decision making forum?
• Collaborative writing group?
CLAHRC
for South Yorkshire
Six projects and two evaluations
since July 2012
Care Commission Group (CCG) Partner /project
•
•
•
Sheffield CCG
Sheffield CCG
Sheffield CCG
•
Sheffield CCG
•
Sheffield CCG
•
•
Doncaster CCG
Doncaster CCG
Whole systems planning for unplanned care
Evaluation of the Emergency Care Practitioner
Service
•
Doncaster CCG
Evaluation of the Glaucoma Care pathway
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for South Yorkshire
Planning Implementation of the Virtual ward pilot
Evaluation of User Experience- Virtual ward pilot
Integrated Care Planning tool- Practice based
implementation
Review and planning for unscheduled care and
Right first Time
Evaluation design for Right First Time
Recruitment;
Knowledge Mobilisation Projects that enable managers to
use evidence and to think critically about the best choices
for improvement (in commissioning decisions and provider
service re-design)
This is encompassed in the simple
question to the partner/project
managerWhat are we trying to achieve?
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for South Yorkshire
Core Principle;
Whole systems thinking
• “You can’t solve problems
with the same thinking that
created those problems.” Albert Einstein
• ......is a method of analysis and
decision-making that looks at
the interrelationships of the
constituent parts of a system
rather than narrowly focusing
on the parts themselves.
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What are the characteristics of
whole system working?
Services are responsive to the needs of the individual patient/ client/
tenant/ carer.
All stakeholders accept their inter-dependency and the fact that the
action of any one of them may have an impact on the whole system.
There is agreement between the stakeholders as to the vision of the
service( s), the priorities, the roles and responsibilities, the
resources, the risks and the review mechanisms.
Those using the system do not experience gaps or duplication in
provision.
Relationships and partnerships are enhanced.
DH (2009)
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for South Yorkshire
Wider
environment
Stakeholder needs and
demands
Organisational objectives
Inputs
Processes
Performance indicators and
measurement systems
Outputs
Outcomes
Performance management
systems
An analytic framework for performance management.
Source: Drawing on Bouckaert and Halligan (2008), Moynihan (2008) and Talbot (2010)
CLAHRC
for South Yorkshire
Methodology
• Mixed methods in organisational
development including;
• Evaluation (collecting and using data) and
• Participant enquiry (seeking consensus
and critical engagement in practice
decisions)
• Promotion of key principles (systems
thinking, user/carer engagement,
appreciation of inequalities)
CLAHRC
for South Yorkshire
Tools to support enquiry and planning
Aim
The ‘big’ dots
Ask yourself
•What is the big (possibly
strategic) problem you are
addressing?
•What are you trying to achieve?
(aim)
•How will you know a change is an
improvement ? (outcome
measures)
Drivers
Interventions
The ‘small’ frontline dots
Ask yourself
Ask yourself
•What are the problems that cause
the bigger problem?
•What are you trying to achieve?
(aim for each driver)
•How will you know a change is an
improvement ? (outcome
measures for each driver )
Which in turn contribute
directly to the ‘bigger’
aim
What changes can you make that will result in the
improvement you seek?
•What are the change ideas / interventions/
solutions to test with PDSA cycles before
implementing?
•How will you know a change is an improvement?
(process measures for each intervention)
Contribute directly to the drivers
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
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Intervention 3
Engage Expert patient
programme
Evidence based models of
care to activate patients and
staff in relation to planning
care and self management
Activate user/carer groups
Intervention 1
EXAMPLE 1
'Right first time' have used
risk stratification tool to
identify patients (39-50)
with unmet need
To establish
integrated care planning
in primary care to
improve patient
outcomes and reduce
admissions
Investment from CCG
via GP association
Intervention 2
Intervention 3
identify patients to include
with particular unmet need
Patient motivation and
engagement needs to be
a priority to achieve better
outcomes
Intervention 2
Intervention 3
Intervention 1
Re-configuration of
community services to
support the patient group
Intervention 2
Intervention 3
Intervention 1
CCG funding to GP
practices may support
local initiatives
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for South Yorkshire
Intervention 2
Intervention 3
Strategic
aim
Primary drivers
Secondary drivers
To embed innovation and quality improvement into curricula and workforce
education training and development processes
Develop shared values:
Create a receptive
environment and context for
quality improvement
Engage stakeholders
Align to strategic priorities
and develop wider corporate
understanding
Engage clinical partners and
organisations
Reinforce partnership
working
Redefine HR job roles and
capability
Actions / interventions
Initiate conversations at
LETC level
Ask stakeholders about
priorities: students patients
etc
Define common
understanding of ‘Quality
Improvement ‘
Provide clinical partners with
support in improvement
Provide faculty with support in
improvement
Embed in curricula
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Identify QI teaching
opportunities and refresh
interprofessional curricula
Develop Open School
Chapters
Develop buddys / mentors
across and between providers
Identify QI teaching
opportunities and refresh
undergraduate curricula
Identify OI teaching
opportunities and refresh Post
graduate curricula
Example 2
Core processes for
all projects
• Driver Diagram (defining the problem)
• Systems measures (to agree the quality
outcomes)
• Leading change in the right direction and
sustaining change is extremely difficult without
relevant measures and management of those
measures.
• Providing a leadership and management
support to achieve those objectives, is also part
of the theme activity.
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System Measures introduced were
possible to inform local
improvements
• against the policy backdrop
• recognising the 'the bottom line' and also
the aspirational- quality improvement
• demonstrating and monitoring trends
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for South Yorkshire
Policy Backdrop;
National Frameworks
• Everyone Counts
• NHS Outcomes
Framework
• CCG Assurance
Framework
• CCG Quality Premium
• CCG Local Delivery
Plan
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for South Yorkshire
National Requirements
Local Requirements
Initial Themes in Innovation in
Commissioning
• These are based on knowledge exchange;
• Impact of projects on commissioning practice and
service improvement.
• Level of satisfaction with the outcomes in terms of
shared understanding and system's planning?
• Willingness to remain engaged with CLAHRC SY and
academic partners?
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for South Yorkshire
Themes and learning
from the work
1.General Practice as a business entity is
responsible for the access of patients into the NHS
and can probably improve their performance more
substantially than is currently by managing
demand and service utilization
2.Highly variable patient consultation/engagement
results in poor / profession centric understanding
of needs of all services to offer wider access.
Patients and staff want emergency care close to
home!
CLAHRC
for South Yorkshire
Themes and learning
from the work
3. Virtual ward- aim to co-ordinate community
services with GP practices and re-focus role of
community matron, particularly with risk
stratification tool as indicator of intervention and
outcomes (evidence is patchy but makes sense to
nurses and other workforce)
4. Integrated care planning in GP is limited by QoF
(poor motivation on financials) and lack of
knowledge and activity related to team
performance
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Themes and learning
from the work
5. 111 and ECP services present alternative
options for out of hours, emergency, and
integration of social prescriptions and social care
may alleviate isolation and combined factors that
cause exacerbation of LTC. Cost benefits of the
different initiatives are probably to complex to
measure
6. Overall, very difficult to know what works to
prevent unnecessary admission- case
management may not help? Is case management effective in reducing
the risk of unplanned hospital admissions for older people? A systematic review and meta-analysis
http://www.ingentaconnect.com/content/oup/famprj/2013/00000030/00000003/art00004
CLAHRC
for South Yorkshire
But
7. Poor planned care will certainly have an impact
on unplanned care pathways and systems
measures for palliative care (in particular) are
going to test this. This interrelationship is not being
addressed currently.
8. Focus on unplanned care and admission rates
tends to refocus on secondary care rather than
stimulate innovation in community and primary
care for older people
CLAHRC
for South Yorkshire
Innovation in Commissioning- Theme Event
Friday 20th September 2013 Voluntary Action Sheffield - The Circle, Rockingham Lane
12.00pm -5.00pm
Discussion
ACKNOWLEDGEMENTS:
THIS PRESENTATION PRESENTS INDEPENDENT RESEARCH BY THE COLLABORATION FOR LEADERSHIP IN APPLIED HEALTH RESEARCH AND CARE
FOR SOUTH YORKSHIRE (NIHR CLAHRC SY). THE VIEWS AND OPINIONS EXPRESSED ARE THOSE OF THE AUTHORS, AND NOT NECESSARILY THOSE
OF THE NHS, THE NIHR OR THE DEPARTMENT OF HEALTH.
CLAHRC SY WOULD ALSO LIKE TO ACKNOWLEDGE THE PARTICIPATION AND RESOURCES OF OUR PARTNER ORGANISATIONS. FURTHER DETAILS
CAN BE FOUND AT WWW.CLAHRC-SY.NIHR.AC.UK.
© SHEFFIELD TEACHING HOSPITAL NHS FOUNDATION TRUST AND ALL OTHER PARTNER ORGANISATIONS 2012, A MEMBER OF THE NATIONAL
INSTITUTE FOR HEALTH RESEARCH COLLABORATIONS FOR LEADERSHIP IN APPLIED HEALTH RESEARCH AND CARE FOR SOUTH YORKSHIRE
(CLAHRC SY).
CLAHRC
for South Yorkshire