How to build motivation and energy to enable innovations and improvements to spread and be sustained is a long-standing challenge. Models of pilot and roll out achieve success but often not to the extent or pace that is wanted.
In this blog Kate Pound shares with me her experience of developing a new model which is based on wide and early involvement of people, and which led to great success. This model was created to support the development and spread of NHS continuing healthcare. NHS continuing healthcare is free social care arranged and funded solely by the NHS for some people with long-term complex health needs and is provided outside of hospital.
These experiences are from Kate's time working with us in NHS Horizons. Kate now works as an Improvement Manager in the Emergency Care Improvement Support Team (ECIST).
As we'll discover in this blog, Continuing Healthcare Improvement Collaborative (CHC) and the way it worked helped produce better outcomes, better experience and better use of resources - many benefits for staff and the people they care for.
Creating the new model
The CHC started with just a few people, all of whom were passionate about improving how care is provided outside of hospital. These few grew to a core team. Key people and organisations involved in the early stages included Helen Bevan, Kate Pound, ADASS (Association of Directors of Adult Social Care) and ECIST (Emergency Care Improvement Support Team).
A system level approach was taken where the unit of activity and engagement was defined as the local authority and the CCG (Clinical Commissioning Group). Commitment from senior leaders from both these organisations in each area was essential for them to participate in the collaborative. Senior level support for this work was demonstrated by ADASS and the system Chief Nurses and Directors of Finance who jointly invited systems to attend a virtual launch event at which a senior NHS England staff member presented.
The model was modified over time, through iterative development, to include three groups [see figure]:
Development group. These systems were the innovators of the new ways of working and were all heavily involved in the programme learning, testing and change.
Test and Scale group. Due to the large number applying to be in the development group, this additional group was formed to be a ‘sounding board’ and to test the new approaches designed by the development group in their own context. This wider testing helped identify the ‘spreadability’ and adaptability of the new way of working and increased understanding of what the key elements were of the new way of working and the potential to replicate the benefits in other areas.
Improvement Community. A crucial element was the third group, a wider improvement community which engaged all interested systems and teams right from the start of the work. This engagement built early relationships, enabled widespread sharing and learning, and generated the momentum that helped create a pull for the new ways of working.
How was the model delivered?
There were 26 applications to join the development group. Ten systems (CCGs and their local authorities) were selected; these included a spectrum of systems, some who were struggling and some ‘traditionalists’ who were believed to be more resistant to adopting change and sat at the far right end of the Rogers innovation diffusion curve.
The remaining 16 system applicants joined the test and scale group. The improvement community included all systems who were invited to contribute and who engaged regularly with the programme. More than 1,000 participants supported the development group and test and scale group with most of the interaction and work delivered virtually.
The collaborative used multiple methods of communication. Crucially most communication was virtual via WebEx (average attendance ~ 100). The few face-to-face meetings were for the development group. In addition, an active Facebook page enabled an energised community to connect and share and the website provided information. This virtual approach allowed for wide participation and was utilised several years before the COVID epidemic forced many activities to work in this way.
The CHC received financial support for the first two years at a national level. While systems joining the collaborative received no additional funding, most meetings were conducted virtually saving time and money in travel and venue costs.
What the model delivered
Kate described to me how the initiative ‘touched a nerve’, the energy of change was great and more than 100 project ideas were created.
The improvement community informed the programme design, workstreams were developed and recommended and then people were employed to work in them. This contrasts with a more typical model of a national programme with workstreams and priorities already decided at launch.
Outputs included a website, an active community e.g. Facebook page and the demystifying of CHC for all by producing a clear message. A webinar to engage front line staff identified the need for policy change and resulted importantly in a major contribution to the revision of the National framework for NHS continuing healthcare and NHS-funded nursing care.
What impact did this work have?
Kate described the benefit
'Working in this model accelerated change and spread whilst delivering significant quality benefits and cost reductions’.
The collaborative helped produce better outcomes, better experience and better use of resources by generating agency for change.
- Better outcomes - increased transparency and engagement and decreased complaints
- Better experience - standardised the patient journey to reduce unwarranted variation
- Better use of resources - reduced transaction time by removing duplication. Continuing Healthcare (CHC) expenditure stabilised, with lower growth than forecast in each of the last three years. This made a major contribution to delivering the £855 million reduction in CHC financial growth which was delivered two years ahead of the planned programme.
What are the advantages of this model for adoption and spread of change?
- Engages a mass of contributors from the start and makes the process of spread much easier and successful
- Builds an active, large virtual community
- Maximises agency for change.
- Enables emotion, commitment and trust to be built up over time
- Achieves greater reach at much lower cost than traditional approaches achieving opportunity cost savings
- Is underpinned by co-production as developing products with front line staff.
- Offers a highly adaptable model
What made this model so successful?
Kate explained that key to success of the model was:
- Important topic with opportunity and need for improvement
- Senior key people and organisations actively participating from the beginning
- Passion, commitment and energy of key people and subsequently the wider community
- Planning for spread from the start which informed the design of the collaborative
- The inclusive nature of the model which generated energy and agency
- Use of virtual communication to enable maximum participation
- Met the needs and expectations of the participants and stakeholders
- Transferable skills gained were applied in new areas of work
- CHC lead who worked convening and connecting the systems.
A second blog will explore the role of system convening and look at how the seven interconnected principles for spread and adoption apply to this model.
More information on complexity, system convening and the 7 spread and adoption principles is available on the NHS Horizons website.
In April 2017, NHS England started a two year NHS Continuing Healthcare Strategic Improvement Programme (CHC SIP) to look at how Continuing Healthcare (CHC) services can be improved. A key part of CHC SIP was CHC Improvement Collaborative which brought together local healthcare leaders and CHC experts, allowing and supporting them to work together to help improve services for the population.
Agency – the ability of an individual or a group to choose to act with purpose
NHS continuing healthcare – also known as NHS continuing care or NHS CHC – is free social care arranged and funded solely by the NHS for some people with long-term complex health needs and is provided outside of hospital.