Despite a plethora of initiatives and investment, growing demand has continued to outstrip ability to respond to needs in North West London (NWL); whilst cuts in social services have left many people who are medically fit to go home, stranded in hospital beds which are needed to treat new patients.
NWL exemplifies these challenges, with 2.3 million patients and over £4 billion spent annually, split across 8 local authorities, 8 clinical commissioning groups, 10 hospitals and multiple local providers. NWL has a well-established history of joint-working, but many services still operate in silos, with duplication, gaps and inefficiencies meaning that patients receive a poorer quality of service than they deserve.
Separate commissioning of services has resulted in a complex system of incompatible processes and pathways between local authorities and across hospital sites.
Our solution was to co-design and roll-out a single function across NWL, integrating health and social care staff, focused on:
Improving the experience and outcomes of care for patients, regardless of which borough they live in or which hospital they attended.
Reducing critical capacity pressures on local acute services.
In practice: WLA engaged with over 200 staff and managers across 8 organisations throughout the proof-of-concept, co-design and implementation process.
WLA standardised over 100 existing and varying processes into 4 clearly defined pathways and one set of principles for the choice policy.
WLA implemented a new virtual operating model, targeting 50% of all complex patient discharges across 4 hospital sites and 3 local authorities.
WLA implemented a clear governance process to ensure rapid decision making.
WLA trained over 100 staff who work in hospital discharge, in six training sessions, and 9 staff in the local Learning and Development teams, in a ‘train the trainer’ session, in order to focus on the behaviours needed to make the new model a success.
The WLA approach is based around 6 core methodological principles of ‘whole-system’ organisational change which have been co-developed with NHS, local authority, academic and consulting partners. These principles are weaved into the change management approach and they demonstrably deliver value to the patients:
Enable and empower citizens and frontline professionals to take a leading role in organisational and system change.
Work jointly to understand, interpret and adapt new models of care to the locality – rather than just accepting them as ‘the solution’.
Work on the principle of evolution rather than pure innovation – changing the small things quickly, to create areas that are ‘change-ready’.
Create a local dialogue around disruption over continuity – conversations about how change is going to be managed, rather than whether it will occur.
Focus on the one to three year time frame – not just the next six months or five year forward view.
Develop genuine support networks and ‘safe spaces’ between peers on the same journey – across organisational and geographical divides.
The WLA change Programme Team operates a permanent, multi-disciplinary consulting team focused on enabling health and care transformation. For this project, we deployed:
Front line staff from a range of professions (social workers, nurses, therapists, …), team managers and leaders from the hospital discharge teams.
Senior consultants and analysts with core expertise in process mapping, data analytics, pathway design, project and change management.
Experts in health and social care commissioning and provision.
Senior facilitators, trainers, and learning and development specialists.
The Programme Team established a true partnership with all stakeholders within the WLA, managing the complexity of liaising with stakeholders across several organisational boundaries (LA, NHS, commissioners), across professional boundaries (clinicians, managers, leaders), as well as across seniority levels (front line staff through to chief executives). Getting the right answers was not enough: it was crucial that each organisation was bought into these answers and owned them.
Outcomes to date include: 89% of NHS and 79% of Local Authority staff believe the pilot has been effective in improving the patient/carer experience with discharge – a 63-68% improvement on Friends and Family Tests on two wards.
89% of NHS ward staff and 79% ASC staff believes the new model and approach has significantly improved the overall discharge process.
63% of NHS staff believe the pilot has reduced the LOS of patient
Approximately 5-10% decrease in referrals into higher levels of care (e.g. increase in home care support, reablement, placements).
DToC Figures for Three Boroughs patients at Charing Cross (the Three Boroughs integrated team launched in March 16), shows almost a halving of DToC from the previous year: Total 2015=124, total 2016=67.
In terms of financial benefits of the project, it is estimated that:
A reduction in DToC will yield £963,208 of savings.
A reduction in unnecessary readmissions will yield £1.1m of savings.
In terms of improved quality of care, the CQC Adult Inpatient Survey shows that patients in Chelsea and Westminster Hospitals:
Were more involved in their discharge decisions in 2015, compared to 2014.
Were given more notice about their discharge destination in 2015, compared to 2014.
Had their family/home situation taken more into account, during discharge planning, in 2015, compared to 2014.
The WLA worked in partnership with:
Central London CCG.
Central London Community Healthcare NHS Trust.
Chelsea & Westminster NHS Foundation Trust (CWH).
Westminster City Council (WCC).
Hammersmith & Fulham CCG.
Imperial Healthcare NHS Trust.
London Borough of Brent.
London Borough of Ealing.
London Borough of Hammersmith & Fulham (LBHF).
London North West Healthcare NHS Trust.
Royal Borough of Kensington & Chelsea (RBKC).
West London CCG.
The model is now being developed for nationwide application, across NHS and local authority services.
This initiative will also be relevant to neighbouring LAs, whose residents attend out of borough hospitals. These include the local authorities of Harrow, Hillingdon and Hounslow, and the Royal Free Hospital NHS FT: contact has already been made with them to explore the extent to which they could join the hosted model.
The new hospital discharge processes require all staff to be able to work and communicate effectively across organisational and professional boundaries, to handle conflict constructively, to feel confident to challenge colleagues and to build positive relationships.
We spoke to staff from all organisations involved and from a range of professional groups to discuss what they needed to feel confident in the new ways of working. Staff said that as well as technical information on the new processes, they wanted to focus on the behaviours needed to make the new model a success.
WLA trained over 100 staff who work in hospital discharge, across 6 training sessions, and 9 staff in the local Learning and Development team in a ‘train the trainer’ session. The resulting model for improving hospital discharge is not only being adopted across NWL, but feeding into New Models of Care work across England as a whole.