The importance of local systems
In our 2018 report Beyond Barriers: How older people move between health and social care in England, we wrote that health and care services can achieve better outcomes for people when they work together. We found that joint working was not always easy, that the health and social care system was fragmented and organisations were not always encouraged or supported to collaborate.
An effective system that supports older people to move between health and care services depends on having the right culture, capability and capacity. In the work for that report, we looked for effective system-working and found examples of the ingredients that are needed. These include:
- a common vision and purpose, shared between leaders in a system, to work together to meet the needs of people who use services, their families and carers
- effective and robust leadership, underpinned by clear governance arrangements and clear accountability for how organisations contribute to the overall performance of the whole system
- strong relationships, at all levels, characterised by aligned vision and values, open communication, trust and common purpose
- joint funding and commissioning
- the right staff with the right skills
- the right communication and information sharing channels
- a learning culture.
What underpins good collaboration
In response to COVID-19 (coronavirus), we have recently talked to representatives from a range of local stakeholder organisations and reviewed local support plans to gather perspectives on the extent to which these characteristics have been to the fore among providers working together to tackle the crisis.
In this issue, we are highlighting the early findings from the feedback we have received around approaches to secure collaboration, and examples of the positive impact of these efforts. In future issues, we aim to further explore what challenges there have been to effective collaboration, share collective learning on what might be done to overcome the barriers to it, and focus on the experience of people moving within the system.
What are the most important actions that health and social care providers can take collectively to manage the response to coronavirus?
A number of the characteristics highlighted above were seen as important in the conversations and feedback that we had from stakeholders. There was an acknowledgement of the importance of establishing a clear local picture, to identify priorities for support, and to ensure that all stakeholders within a health and social care system are on the same page, with an agreed strategy that all stakeholders are signed up to, and effective communication plans.
Collaboration was seen as vital, with strong relationships between providers and across sectors being the key to the success of managing in a crisis. Positive working relationships reduce the time taken to accomplish goals – for example in procuring personal protective equipment. The discharge and flow of patients between and within appropriate care settings was crucial, and this is influenced by the quality of relationships between providers (for example, between care homes and acute trusts). Similarly, collaborative working between local authorities, acute trusts and clinical commissioning groups was important to ensure timely access to clinical advice for care home staff.
In responding to coronavirus, how have leaders collaborated to plan and deliver services and support staff across providers to work together?
Most of the people we spoke to and the support plans we reviewed indicated that the collaboration by local leaders in their areas had been very effective in planning and delivering services and supporting staff across providers to work together. This included:
- Setting up meetings and working groups – these were regular (usually daily or weekly), with some areas making use of existing meetings and networks to make the most of existing relationships. Membership varied but could include a range of service types (local authorities and councils, clinical commissioning groups, ambulance services, primary care networks, acute, community and mental health trusts, social care and voluntary sector) and roles (including public health, performance monitoring and infection control leads).
- Providers working together to reduce the spread of coronavirus – working especially to make sure supplies of personal protective equipment were available across services, supporting local testing, and working to make training in infection prevention and control available.
- Monitoring data and ensuring capacity across the system – for example using independent hospitals or volunteer networks to pick up some of the activity or demand that could not managed during the peak of the pandemic. In addition they used data and intelligence to identify services most in need of support – for example by monitoring the availability of personal protective equipment (PPE), the number of people with suspected or confirmed coronavirus, and workforce data.
A number of stakeholders said that working together on the response to coronavirus has led to improvements to local system working: better collaboration across services, breaking down of longstanding boundaries, and better understanding of all services available in their area.
What barriers have there been to provider collaboration in responding to coronavirus?
Our conversations yielded a range of responses on the barriers that stakeholders had faced in collaborating to respond to the crisis.
- Good collaboration depends on good communication and dialogue between partners, and there was a feeling that there was room for more dialogue between primary and secondary care. Quickly establishing shared responsibility was a challenge when set against the statutory responsibilities that some organisations hold.
- A need to share resources fairly (across a wide range of areas: redeployment of staff, medicines, workload and PPE) and in a timely way was a big challenge – this was most successfully overcome by a sheer ‘willingness to collaborate’ to get the job done and through joint discussions and solutions.
- The need to work at pace has been a big challenge – the sheer speed with which changes to procedures and guidance were made has been difficult to manage, as has been maintaining governance oversight at speed. Acute trust stakeholders also highlighted that NHS structures do not aid quick decision making.
- Ensuring the delivery of the right information was a barrier when the need to answer daily requests for information was so prevalent. Duplication of information requests was sometimes a problem too.
Collaboration – examples from the front line
On 4 June, we published a wide range of examples from the front line, which health and care providers from all sectors had shared with us showing how they have innovated and adapted working practices to respond to the challenges of coronavirus. Here are three of those examples of working together that highlight the characteristics of good collaboration.
St Helena Hospice agreed with the Suffolk and North East Essex ICS to take on a leadership and coordination role for all end of life care delivered outside of hospital in North East Essex during the pandemic.
Mark Jarman-Howe, chief executive of St Helena said, "The COVID pandemic has brought huge challenges to community palliative and end of life care. In North East Essex, St Helena Hospice coordinated the community end of life response on behalf of the North East Essex Health and Wellbeing Alliance, creating a hub and spoke model. Non-urgent hospice visiting ceased and community specialist nurses, rehab and family support teams joined the single point of access team to create an enhanced community rapid response hub. Continuing health care funding resources were allocated through the hub, and local voluntary services coordinated relief services for those on the palliative care register. We created a 24-hour non-medical prescriber rapid response service in partnership with Anglian Community Enterprise to enhance overnight nursing capability and offered bereavement services across the community.
"We created integrated spoke teams with weekly virtual meetings between primary care, community nursing and the hospice, and developed a single caseload between the providers to enhance care coordination.
"We developed our electronic palliative care coordination system to capture advance care planning discussions about COVID and gained access to it for care home staff. We rewrote anticipatory prescribing guidance, verification of death procedures, created patient group directives, wrote policies to allow hospice medications to be taken into the community for urgent visits and supported carers to learn to administer subcutaneous medication. We expanded the hospice inpatient unit and also a virtual ward in collaboration with a local care provider and merged community hospital and hospice beds into an integrated community bed base. We taught colleagues across the community about symptom control and advance care planning. We ate a lot of cake and spent a lot of time on Microsoft Teams.
"Three months later, what do we know? We learned, like many others, that a crisis created more inter-organisational co-operation in two weeks than years of previous meetings. We learned how many more people can be cared for in the community at the end of life when organisational barriers are dismantled. A crisis made us do it differently and showed us what can be achieved when organisational barriers are broken down and service is driven by the needs of the patient."
Carebridge have run a bridging service for the last two years from September to March to facilitate safe and effective hospital discharges. This service was extended during the pandemic and they tripled their hours to provide a 72-hour implementation period.
Carebridge supplied Hertfordshire East and North CCG and were approached to set up the service. This consisted of well-trained carers and nurses who had been carefully selected to safely respond to the patient’s needs with the relevant clinical skills. Early steps were taken before being instructed to supply full barrier nursing PPE including facemasks and eye guards.
Along with discharge teams in Herts social services and continuing health care, Carebridge agreed a full process and management plan and tracked daily to measure effectiveness, response times and client needs. They implemented a referral form to collate the necessary information before assessment, and then on discharge deployed a response car with an appropriately trained individual to complete the assessment at home.
The number of hours and needs fluctuated daily. They flexed care hours in response to needs, rather than requesting a block contract, offered counselling and engaged with voluntary support services for all clients and members of the team. There were regular supervision sessions with the in-house clinical team for those dealing with difficult circumstances. The senior management team shared an on-call rota and provided clinical support when required. All staff received additional training on coronavirus, including how to safely apply and discard PPE, and resilience training was included for more complex cases. The above process was discussed at bi-weekly conference calls among the clinical governance team to ensure quick changes of practice to ensure best delivery outcomes and optimum care.
Carebridge also supported additional tasks such as shopping, collecting medicines and dropping off PPE. They also implemented a nutrition and hydration project at the same time, dispensing slow cookers and menus to families that were isolating and relying on staff to receive home cooked, fresh meals.
The De Parys Group in Bedford has been working to provide services tailored to the needs of its predominantly older patient group.
A multi-disciplinary group meets fortnightly to review older patients referred to the group by any health or social care professional. Membership includes GPs, community nurses, social care professionals, mental health professionals, social prescribers, and practice nurses who lead on care home support. This group has been well supported by its members and the senior teams in the respective organisation. It has been very successful in reviewing and case managing vulnerable older people and developing care plans, and provides a clear focus for all health professionals when they are concerned about a patient, especially where a multi-agency response in needed.
The De Parys Group has been working closely with care homes aligned to it. This includes providing a named point of contact in the surgery; phone ‘check-in’ on a weekly basis; clinical leadership through a named practice nurse with special interest; and medicines reviews conducted by its clinical pharmacists in conjunction with the CCG ‘Medicines Optimisation in Care Homes’ team.
It has also been supporting the care homes by supplying PPE and helping them to set up video consultation capability. During the early coronavirus period, it worked extensively with the care homes to ensure all patients had an up-to-date advanced care plan and that their wishes regarding DNAR were clearly documented. It is continuously developing its joint working with care homes and has developed a Project Charter to guide this work.
The service offer for older patients has included home visits – taking on considerable amounts of wound care and phlebotomy for housebound and vulnerable patients, therefore supporting the district nursing services during the crisis.
The group also developed the first red site in the region, and then worked collaboratively with partners to upscale it to deliver for the whole borough. It is seen as the model of a collaborative working across Bedfordshire, Luton and Milton Keynes, our integrated care organisation area.
In future reports...
In the next edition of this report, we will report further on the themes arising from the conversations we are having with local leaders about collaboration among organisations to respond to the pandemic.
In addition, we are carrying out a rapid piece of work, engaging with partners and using our data and intelligence, to review how providers are working collaboratively in response to the coronavirus pandemic.
The speed and scale of the response required by the coronavirus pandemic has highlighted how any fragmentation in our current health and care systems may significantly impair the ability to respond effectively.
These Provider Collaboration Reviews will involve understanding the journey for people with and without coronavirus across health and social care providers, including the independent sector and council and NHS providers.
We are focusing on the over-65 population because of the risks that have emerged between health and social care, supporting the providers and people living in care homes and/or receiving home care. While there are risks to all population groups in a fragmented health and care system, we have decided to focus initially on those aged 65 and over given the size of that population group.
This work will support providers by sharing learning and best practice from local areas working together, across the country. The reviews will include experiences of people who use services.