New Care Models Letter
Dear Suzanne,
Firstly, thank you to you, your teams & partners for hosting and participating in the Vanguard
site visit on 18th – 19th May 2015. It was a pleasure to meet with you, your senior leadership
teams, the voluntary sector, and the wider stakeholders including citizens who are involved
in developing and receiving care services. Please pass on our thanks to everyone who
helped make the two days so informative and enjoyable.
As you know, we captured learning from the two days through observation, reflections and
through our dialogue together. We have grouped our feedback into theme areas which we
know need to be addressed for major change to succeed. I trust that this letter reflects our
discussions when we met, and I look forward to working with you to develop the Isle of Wight
PACS Vanguard.
Vision, objectives and progress
During the visit we heard about My Life, A Full Life (MLAFL), your vision to make personcentred, co-ordinated health and social care support a reality on the island, through the
creation of integrated health and social care teams, led by primary care but very much
including the wider community. Already, your work has exposed the fault-lines of
fragmentation and the approach of managing through a series of entities. As such, we
encourage you to address examples of where the current organisational approach produces
inefficiencies and frustration leading to poor outcomes, and ultimately eliminate them.
You have a strong brand and an impressive range of organisations involved in the design
and implementation of the new care model. Given this strong context for your work, we
would encourage you to consider increasing the pace and scale of your implementation at
locality level so you can learn from the experience you gain and start to improve the
outcomes for your population. We are confident that you will be able to deliver on a more
ambitious plan, as we have seen your clear achievement to date of gaining alignment of
intent and vision, resulting in demonstrable energy, commitment and passion to drive
forward your plans.
The ability to move care out of the hospital setting will require capacity in the community
which requires multiple providers including GPs. You recognize that you have more work to
do to get the GPs fully on board and owning the new care model, increasing the ownership
at GP level will enable you to deliver more are scale and pace.
The new care model for MLAFL could benefit from clearer articulation and design of mental
health related care as this was not as strongly articulated as the physical health and social
services aspects of the care model.
You also discussed your forthcoming review of services on the Island as you develop your
thinking on choice, feasibility of sustaining the wide range of services on the Island whilst
delivering high quality outcomes. We agree with you that this service review is key to
developing the future care model and the ongoing engagement and involvement of the
citizens on the Island.
Leadership for change
You present a number of strong leaders in each sector, each of you exerting major influence
in your respective area. Your senior team has been able to articulate a unified vision, and
are working towards “One Leadership” which you describe as a motivational and
inspirational system of leadership clearly paving the way forward.
Your work on developing leadership is admirable. We heard of your intention to build on your
existing TalentWorks primary care leadership programme. We realise that you are eager to
start to work at scale. In order to do this, you will need leadership programmes that are
aimed at developing system wide leadership and a way of enabling capacity for such leaders
to do this. You have recognised the importance of developing leadership at all levels of the
system – in particular to enable “middle managers” to fulfill their role. Thames Valley and
Wessex Leadership Academy have stated that they will continue to be fully supportive of this
work.
Communication and Engagement
The stakeholder event on day two was well attended, innovative in its design, and excellently
facilitated by the voluntary sector. It is clear from all the interactions through the two days
that you are dedicated to involving the voluntary sector however much of this focus has been
on the older population so we would encourage you to reach out to younger people on the
Island so you can support them to interact and get involved in the new care model design
and delivery. You shared with us that although there has been considerable interest and
involvement in the out of hospital care staff that you had more work to day to engage with
those staff who traditionally work in the hospital environment. We agree with you that this
should be a priority and by getting the whole of the teams on board could be an enabler to
accelerating your vision and plans.
Workforce
You expressed to us a number of concerns that you have surrounding your workforce.
Firstly, you highlighted to us the supply gaps and areas of difficulty in local recruiting. These
include: recruitment of domiciliary and care home staff, nurses (both specialist and general),
shortages of GPs and inability to fill training posts. Secondly, you told of issues regarding job
design and HR – you identified blockers in relation to Regulator requirements and CQC
workforce requirements, although it was suggested that Health Education England (HEE)
may be able to help you address these issues. It also appeared that you rely relatively
heavily on volunteer involvement and while this clearly has its benefits, the sustainability of
the voluntary workforce is brought into question given the level of expectation on them.
Health Education Wessex (HEW) has advised that they would be able to provide support to
you in a variety of areas. As an initial step, they can support you in producing a workforce
development strategy and action plan by supplying a single point of contact who can connect
you with HEW expertise. They can also assist your development of your idea of a Centre of
Academic Excellence, in particular to influence HEE and funding approaches going forward.
They can connect you with others in primary care on the changing role of GPs and
Consultants.
Finance, contracting and pricing
During discussions, you described the Finance summit which occurred in October last year,
and how it was identified from that that there is a need for a joint financial strategy, and also
a requirement to consider the funds delivered by the voluntary sector. It is our understanding
that you need supporting contracts for this and will need expertise to assist, as well as place
based budgets and CCG running costs.
We also discussed your new contractual models aimed at empowering providers. You
illustrated this with the example of the diabetes incentive contract model. Together we
identified that there was possibility of partnership with Yeovil Vanguard around different GP
contracts.
Informatics and information technology
You have great ideas overall and some immediate potential to quickly develop in this area by
agreeing your system strategy, rather than working on strands in isolation. We therefore
recommend that you put down on paper a map of core infrastructure, systems and
interoperability to aid agreement in what can be streamlined, replaced completely, or
expanded.
You described your current situation with regards to infrastructure as comprising legacy
systems, non-standard apps and separate networks. Your intention is to create a joined up
network across the island, as well as to integrate the NHS, social care and the local authority
systems. Your standard apps are all currently in silos, with each holding their own record.
You articulated that your plan is to transition to paperless records, shared across
organisations and people, and which is integrated and available anytime, anywhere.
We understand that you already have a link to the 111/999 hub. The next steps are to make
data available from each service so that 999 has visibility of patient history. You are also
already sharing information in emergency for COPD and heart failure, with a plan to expand
this prepared. Furthermore, there is a critical response team for telehealth which provides
service within 72 hours. You have also started the journey to enabling patients to have
access to their own data via a portal.
Comprehending the importance of communicating with the public, you acknowledge that
information governance is a key barrier to information sharing, however we see that you
have a sharing protocol in place and will expand to primary care.
We feel that the radical piece in all this will be the pace of implementation, and we realise
that pump priming will be needed to support this. Furthermore, our discussions showed that
a change in culture is also necessary – both to use IT and create digital ownership and to
push past the NHS and other public sector organisations traditional risk adverseness.
Measurement and evaluation
You have shown that your programme is very much built on MLAFL, and it is promising to
see that you have already begun to think about your summative evaluation and have
prepared a research protocol. Logic modelling has been created as a part of this MLAFL,
and you have been developing your logic model over the last 16 months, and during this
process you have been leaning more towards developing a “how” and “why” of the new care
model and establishing the counterfactual.
A suite of metrics for MLAFL was presented to us, but you were careful to point out that
these are limited due to annual updates. You described how a qualitative evaluation is being
used in the short-term, while further work is being carried out to develop short-, mid- and
long-term metrics.
In terms of evaluation, you have stated that you are working closely with Southampton
Solent University, and a two-year initial evaluation is being conducted. Other universities
which you are receiving support from include York University for cost-benefit analysis and
Leeds University for assessing how evaluation can be used in the development process of
integration.
You recognise a number of challenges in the measurement process. Firstly, you feel that
there is a need to define the cohort of patients that the interventions within the Vanguard are
targeted at, and then to curate level 1 metrics. Secondly, you realise that there are cultural
challenges straddling health and social care. Thirdly, you identified that measurement and
evaluation must drive change going forward.
We heard your ask for support from us in a number of areas. These include: breaking the
information governance barriers for individual patient data; coupling together of quantitative
and qualitative data; bespoke data collection; sharing of information with other vanguards
and expert advice on co-production of evaluation.
Next steps
We suggest that you dedicate time to consider the feedback received following the site visit
before further developing your programme delivery plan for 2015/6 and the details of support
you would need for a roadmap, programme management and leadership capacity for the
Vanguard. We asked that you think about not only the areas for support, but also how and
when this support might best be delivered for you. In doing so, we suggest you focus on the
following key areas:
1. Developing the scalability and pace of your vision and plans.
2. Consider the role of GPs in the design of the new care model and what rules need to
change to enable GPs to fully embrace working differently.
3. Consider the scope of the review of services, the timing of this review and the impact it
has on the new care model.
4. Consider your requirements for whole system leadership and workforce strategy and
planning including the development of a Centre for Excellence.
5. Consider the support you require to enable you to make the changes to the contracting
model you are envisaging and the financial modelling that supports this.
6. Developing your technology capability including working across the three vanguards in
Wessex.
7. Developing your ‘ask’ of the National team in respect of measurement and evaluation.
We look forward to receiving the above in writing from you. We will then consolidate this
with the feedback from other Vanguards before finalising the initial package for Isle of Wight
Vanguard.
Once again, please accept our thanks for welcoming the New Care Models team and
colleagues to Isle of Wight Vanguard. Your mutual commitment to improve the care and
support for local people was hugely energizing and embodies the spirit of the Vanguard
programme. I know I speak on behalf of colleagues from the team regionally and nationally
in saying that we are very much looking forward to working together in developing and
delivering the new care model.
Yours sincerely,
Sue Loseby
PACS Lead
New Care Models Team