What is an Integrated Neighbourhood Team (INT) – Part 2

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Transcript

In this episode, I discuss the characteristics that drive success in INT’s.

Evidence and Adaptation

The next piece that we are now really getting quite excited about is when everyone says well, there’s no evidence, what’s the evidence. And of course, we all know the evidence bar seems to have to be higher to get on and adapt something new in the primary and community space than the evidence bar of carrying on doing the things.

That we’ve been doing for many years and we know aren’t evidence based. You know, case in point being, it is not safer to sit in a hospital bed, it is not risk free. Yet we don’t seem willing because we seem to think it’s a risk to adapt to a new out of hospital system.

So what our team have been doing is they have been analysing. All of the different pieces of evidence that exist, both individual pieces, so the sort of examples that will exist in every single one of your parts of the country that lots of them, Claire Fuller wrote up in her stock take and they’ll be written up all over the place about the good things that are operating.

We’ve also looked at some of the meta studies from around the world around what has driven the success that the problem is. You go and see an absolutely brilliant gardening club that’s been set up in Carlisle for refugees. That’s transformed the health and well-being of the refugees in that patch and the sort of thing we’ve done in the past is said, well, every INT in the country must now have a gardening club for refugees. We know that that’s not actually a scalable rollout model and nor may it meet the needs of someone in Whitstable.

So what we’ve tried to do is get under the skin of all of those hundreds, and in fact it’s thousands of different examples around the countries and I said internationally and tried to say what are the characteristics and drivers that sit underneath them. And then we put some money with them.

Step 1: Team Activation

So the first characteristic in every single one of those cases is where there has been a measurable increase in how engaged and activated the team are around their common purpose, around the autonomy, very important, the autonomy they have to act and the confidence and skills of those teams. So that’s step #1 and that gives us both financially measurable outcome and a measurable outcome for the effectively the joy and well-being of that team that have come together.

But you can measure a benefits case around money on this as well as those metrics. So step one in what do you do if you want to create a successful integrated neighbourhood team is get the team together. That does assume we’ve got to align the workforce by the way, slight caveat. And you put the team together and you start investing in giving that team the headspace to align around common purpose.

Step 2: Leadership and Management

Step number 2 is where the management and leadership come. We need to remove all those ridiculous barriers that we’ve created over those years. I was having a discussion with the board of a Community provider who were, you know, telling me all about their Quality and Safety Committee and how that assured them of the safety of all their service. And I said, well, I’ve spent a lot of time with your frontline nursing teams and they tell me that they currently spend about 65 to 70% of their time doing paperwork and a large chunk of that adds no value whatsoever to the patients which they’re working with. And it certainly makes their life tricky because it’s part of pushing people around the system.

Do we not think that it might be a safer and less risky service if we remove some of those burdens and allow those people to actually spend time with patients and with other members of the clinical team on value adding tasks. And that’s not saying all paperwork is bad and it’s not saying digital and tech is bad. It’s saying let’s do the things that are that are right and not things that give us an illusion of safety as opposed to actual safety.

And funnily enough, you’ll know I’m gonna say this, you can measure the improvements on that most people I speak to think that there’s a minimum 25% productivity gain for frontline teams across the board, not just the sort of nursing team example across the board. If what we do is remove the barriers to those individuals working seamlessly together.

Step 3: Proactive Health Improvement

Step 3 is where the real health gain comes, and that is moving from this entirely reactive health service position that we found ourselves in, health and care position, into a more proactive one, so creating capacity in Step 1 and 2 so you can start proactively working with your communities and your population to improve their health.

And we see some amazing examples of this, but the good news is that even asking people the question around how able to manage your health are you, actually activates people in itself and improves outcomes for them.

That is often we’re starting to invest outside of traditional NHS and care services into the third sector, have a massive return, but the real gain comes when you are fully integrated in a community across health, funded services, local authority, local government funded, 3rd sector funded and businesses with communities themselves. The metrics that all of these steps show is a reduction in secondary care demand.

Practical Lessons and Team Composition

So how do you practically go about that and what are some of the lessons? So, absolutely most of the evidence as I just described in that model is bottom up. I’m just going to take a quick cul-de-sac on this. Who’s in the team? That’s another question I get asked all the time. I think broadly, we think you start where it works for you.

And is this health, or is this social care? Is this voluntary sector? Of course, we all know that you only really improve the health of a population if you look beyond the healthcare funded resources.

But what doesn’t work is sitting in lots of management meetings, talking about partnership and how well you all get on and not actually doing anything different on the frontline. So the point of that logic model is it’s about starting on the frontline and starting with the teams.

The care model development needs to start wherever you are in your community, but broadly, the health element of the team we think starts with general practice, PCN, the vast majority of community services, whatever names they’ve got in your part of the world, Community, mental health.

And then the connection to the specialist services in the way I talked earlier, of course it is optimal if you are very closely partnered or fully integrated with social care, children’s services and voluntary sector in that particular hyper local space, that’s actually where the evidence base is.

And therefore 1 of the pieces of scaffolding we talk about is a workforce alignment and a workforce development piece.

But these are the sort of pieces we see in the merger of the top down and the bottom up. I’ve talked a lot about the bottom up, but what else do you need to do to remove those barriers? You need to agree your care model. You need to align your workforce a single estate plan.

None of this happens unless you invest in frontline leadership and team development. As I said, you gotta drive the integration opportunities where you can, rethink how you measure quality insurance to do the real measurement, not a pseudo version of it. That gives you an illusion of quality and safety.

Working with the third sector, the business case I just talked about in some systems now has numbers and becomes the benefits and investment case we are going to invest in all of these factors to deliver these benefits.

Digital, Organisational Form, and Vision

That’s the big thing that’s changed in the last decade, is what digital and tech can do for us and how it can both augment and replace gaps in the workforce. That is a massive thing that’s also changed. Ultimately, does this need a new organisational form? It’s clearly not what you start with, but let’s be honest, we’ve not got an optimised organisational form, so in some places we are seeing discussions now around the merger of GDP alliances / federations with community providers, for example.

So lots of opportunities coming through. This is mental health, physical, health, children’s all age. That’s some of the success criteria.

Success Characteristics

What are the success characteristics that we see? The first is that you have to be brave and you have to have a three-year vision. You have to align your workforce. You have to have a leadership alignment at the frontline and a leadership alignment at the whole system on this. People have to wake up every day with this being a priority, not being distracted with what sticking plaster can we do to reduce delayed transfers of care in and acute hospital?

We’re going to reduce people sitting in hospital beds by creating 24/7/365 accountability for that integrated neighbourhood team for that population. The elastic band may stretch to a hospital stay, but it’s that team that are immediately trying to get people home.

Just saying creating the teams and moving the deck chairs is certainly not enough. You have to invest in headspace for those teams and clever facilitated change to enable those teams to both adapt the culture because we’ve ingrained the culture harder under organisational boundaries recently, in every part of the health and care system, but also the sort of reworking of the wiring diagram. You know that picture I showed you at the beginning with loads of different boxes working in silos. That’s a lot of operational process rewiring that needs to happen and it’s a very particular skill to do it and it’s both digital and workforce rewiring. So you’ve got to invest in that cultural shift and the operational process shift.

I think one of the big things is not thinking we’re going to design a perfect model with all the widgets as I said. And our view is no one-size-fits-all and it’s actually irrelevant where you start. This isn’t all age-based team or all need-based teams.

The absolute worst example, some of the ugly examples we’re hearing about is INT’s are yet another sticking plaster that sits over the mess that already exists. It’s just this year’s, you know, craze is to not call it complex care coordination, not call it a frailty team. This year, we’ll call it an integrated neighbourhood team. That is not the answer.

This integrated neighbourhood teams are about the current teams working differently together for getting the names and sticking plasters that they’ve been given, but also the other thing that we see that we think is a really counter to the evidence where we’ll create an integrated neighbourhood hub and what we’ll do is take the most needy part of the community and we’ll care for them separately in this hub, or we might have put it on the front door of a hospital because that’s where all the specialists are.

That’s not what’s driving the need of those people. The evidence is absolutely categorical that community based support and enhancement, often non clinical, nothing to do with medicalising the model is actually what enable people to live those lives. So starting in a community based with the Community assets is absolutely critical.

System-Level Alignment and Measurement

What you can do is align the bigger picture at a system level to affect via dashboard that each individual INT can use on a monthly basis to chart their progress to the day-to-day huddle about within our community, there’s 10 people who ended up sitting in a bed that’s not their own. How are we drawing them back again and using the skills and resources within our team.

We know that Mrs such as husband died and that leaves her lonely and vulnerable and what’s the response that our team are proactively putting in example? So the day-to-day way of working using the data in the system leads to a dashboard that help you measure your success on a weekly, monthly that lead to the system based outcomes being achieved and resisting the urge to do it the other way around. And talk about demand reduction first. So they’re the sort of characteristics.

What’s Happening Nationally

So what’s happening around the country to do this? We’re working with systems all over the country as I, as I said, there’s the CARE Programme that we run works with lots of individual practitioners who are very keen to take a population, health improvement focus and that still runs around the country. And there’s people from every single system individually trying to develop themselves.

We are working with systems across both the bottom up get the teams together. How do you do the cultural and the process shift with teams? But what they then find is they run into the barriers of the system barriers. So then also you find that can you help systems to unlock those barriers?

Lots of people want to build a business case, that logic model builds that business case out. So lots of work going on all over the country. And one of things we often do with this, as I said, is we go out and talk to people and people like you say, could you come and talk to our leadership team along the lines of the sort of discussion we’ve been doing today and we can unpack this a lot more about what we’re seeing around the good, the bad and the ugly, and how do you do it?

To be honest, the most important question, how do you deliver this? We can come out and talk to you and we’re very happy to follow up and come and talk to your systems about the learning that we’re getting about what works, what doesn’t, what drives success.