In this first instalment, hear as we discuss what an Integrated Neighbourhood Team is and share the learning NAPC has gathered from across the country, working with sites to develop and implement this model.
Transcript
Welcome to the NAPC podcast. This episode is the first part of the discussion around INT’s and what they are. It’s a recording of a recent webinar we held for members. I hope you enjoy.
What I’m going to attempt to do is bring together some of the learning that we’ve had over those many years, across NAPC and across my own personal experiences in this space, but we we’re learning every day. Yesterday we’re in Doncaster. Today, I’m in Truro and I get the luxury now of going around the country and talking to teams. Very frontline teams, leadership teams, through to the national teams around integrated neighbourhood working and picking up what works and what doesn’t.
So the plan today is to attempt to distil some of that learning and bring it forward. The idea is that I’m going to try and impart some of that thinking over the next sort of half an hour to 40 minutes. It will not all be right and actually some of it, I’ll decide it’s not right tomorrow, because we’re learning constantly, but we’re going to pick up a little bit older for any new people, tell you a little bit about NAPC.
Why do things need to change? What’s the national context over this? And I think that’s where some of the stars are really aligning. People often ask me what’s different, and I think that’s where some of it is. What’s happening to actually get delivery at scale?
So, who are NAPC, just very quickly for anyone new to this. NAPC are a membership body. You are the membership. And we are a not-for-profit organisation and we’re focused around leading change and innovation in primary care. But when we talk primary care, we’re not talking just general practice or just dentistry, optometrists, etcetera. We’re talking about a very broad view around primary and community-based care.
We spend our time really in three spaces. All of you are by nature the most innovative end of the spectrum and the people we get to work with are real innovators. They’re innovating at system level and innovating down to individual practise on the ground.
We spend chunks of time trying to make sense and influence the future of the NHS and policy making. But we spend most of our time out on the ground, helping support systems to implement that change, and that’s sort of neatly takes me on to well, why is this such an important agenda? Why is a complete transformation and shift in the way that we deliver healthcare and the way we think about health in the UK so important? And sort of honing that into, why do things need to change in this broad primary community space? So, we all know that we’ve got an increasing level of expectation and demand. We’ve got an unsustainable financial situation. There is there’s been loads of extra money put in. Health have done very well in the recent settlements, but it is very clear this is not a never-ending gravy train. There is actually no new money. We need to drive out efficiencies and productivity and create a long-term sustainable health system.
I think one of the big things that shifted in the last couple of years is the morale and sort of lack of hope in the workforce. I think when I spend my time speaking to frontline teams particularly, but it’s actually true all the way through to the most senior team.
There really is quite a despondency, a lack of enjoyment, people retreating back into just trying to get through their day. And then that comes together with poor delivery methodology. And I’m going to say some of that in a minute. We’ve, well-meaningly attempt to add capacity in the community and primary care space.
But what we seem to have done is just create more handoffs, more silos and more fragmentation to the model, which of course, at the end of the day, who does that affect the most? Yes, it affects the workforce and that makes it unsatisfactory for them but really is very bad for citizens and our patients, who get pushed anonymously around the system. The default is often at the end of life, people spending their time not in their own bed or their bed of choice but defaulting into institutional beds.
Specifically, what have we done in that out of hospital space that primary and community space. Now, Minesh who I work with in the NAPC, is a GP in Sussex and he kindly counted up the teams around him and I can tell you he got over 20 teams that are being well-meaningly created often with tiny pockets of money to attempt to solve the problem of people not receiving the care when they need it. And he had, as I say, over 20 teams, often with the same name or with different names doing the same thing with both overlapping geographical coverage and non-overlapping geographical coverage, every single one had its own front door.
Another example of that, I’m sat in Cornwall today and they were talking about; They picked up every referral form around the out of hospital space only not the in hospital. And they had 150 forms of which they wallpapered a room with it.
And so, of course a large chunk of our team’s time at the moment is trying to navigate an unnavigable situation. And when you ask the teams on the ground well, ‘What’s the difference between your virtual ward team and your district nursing team and your frailty team or the frailty team and the PCN and the frailty team that the Community Trust provide?’, often it’s very hard to tell the difference, but we all know that they all have different sub-criteria and it often falls between.
The one other bit of evidence I’ll just bring in here. There’s a professor in the North East called Professor Joanne Reeve and she did some work looking at GP workload and the depressing thing is that 65% of the increase in workload is often being called the post box of the system.
So, I think we’re rehearsing an argument is unsustainable financially, the one thing I’d throw in here is the best health systems in the world spend more than 50% of their investment in the primary and community space. We all know that you get a 1 pound, 14 pound return if you invest in the wider determinants of health as opposed to in hospital-based care.
Let’s imagine a different world, currently called integrated neighbourhood teams. They used to be called ‘extended primary and community care teams’ in my days in Hampshire in the vanguard area eras some 15 years ago when I was working with the GP’s and that people have called them different elsewhere.
But let’s imagine a situation where you have a defined population, and you have a defined team with a single leadership team who are collectively responsible for both the health and health care of everyone in that community. And they’ve removed all of the barriers that exist and are able to work both proactively and reactively.
Of course, at the moment about 99% of care is reactive and the evidence would say to provide the best health service you need a 50% proactive 50% reactive. And they don’t stop at the NHS funded services, but we’ve rejoined our services with domiciliary care, Care Homes is actually one of our success stories. But really importantly the backbone of society is often those small voluntary sector organisations. They’re reaching the hard to reach, the lonely parts of our community.
And imagine that those people are not defending the boundaries of their organisation and counting meaningless activity figures, but they’re bringing their collective skills and resources together under a single leadership team to improve the outcomes of that population.
And not only are they looking after them when they’re based in their own bed in their own home and their own community, but when they do need a stay within a specialist environment, all that’s happening is that the elastic band is stretching around them while they received that specialist care. And what that’s doing is, that stretch is pulling people back into their own home and their own community as soon as physically possible thinking about completely different way of working between specialist services and primary care services we think is part of the key to this model.
Don’t think that that means that we’re going to suddenly start running a respiratory outpatient clinic in Newquay Hospital. What we think is that what you’re doing is working collectively with the skills of the specialists to look at the health of a population move upstream, to think well, how do we both manage the current respiratory burden of that population and the citizens in it? But how do you actually move upstream preventatively to mean that you didn’t end up with that respiratory burden in the first place and we can come back and talk some more.
So, what’s changed? And you know, we all always think we’ve got a financial burning platform. We’ve always got the worst winter that we’ve always had. We’ve always got, if I’m blunt, the most people residing in hospital beds that don’t need to be there. So, what’s changed?
I think our view is that there is a real alignment nationally with the government policy around enabling neighbourhoods and the wider government policy. With the research and evidence from around the world, as well as the UK and some of the work that’s happened in the NHS, more specifically around a shift to a neighbourhood and a primary community-based model of care and the Secretary of State specifically is very, very clear about his three aims.
But I think broadly the big shifts that’s happening is that the policy agenda is now aligned with the evidence from around the world is aligned with the desire from the people working in the service. And when you look at work like the work London have done, it’s aligned to what citizens and populations think that they want. To be able to be anchored around a team that’s based in their neighbourhood and their community.
Why change? What could a new world look like at that macro level? The national context aligns. I’m going to go on in a moment to talk about the lessons we’re learning about the sort of the good, the bad and the ugly, I often call it. What works, what doesn’t work and what’s worth trying. And it may or may not work.
One of the things I get asked often is ‘what should we tell systems to do to make this INT agenda get implemented?’ and I say you shouldn’t tell them anything. In fact, you should do the reverse. You should remove rules. Create flexibility because the people who actually know the answers are the people out in the field.
So I think that there’s this real tension of the sort of culture and style of leadership that we’ve been working with over the last decade where you sort of here’s a form and you tell us what you’re doing and you count things to a new way of doing things. Again, I think the policy and government position has changed at the same time as there is a desire from the frontline to do this.
When I go around the country, the who’s leading this piece, it varies, if I’m honest, whether it comes from a GP alliance or federation, and that there’s a real sort of continuity of leadership coming from primary care, whether it comes from a Community Trust. In some places in the country, there’s a massive drive from the leadership of the community organisation saying we shouldn’t exist. We need to merge our services back into integrated teams of primary care and social care.
Sometimes it comes from social care and the local authority. You see that very strongly in some places. And in others it comes from ICB / Place. And actually I don’t think there’s a right answer. I think you have to go where there’s the energy for the leadership. I think the one thing I do think is somebody has to wake up feeling accountable for driving this forward and not just getting distracted by either the new shiny thing or the urgent, you know, urgent discharges of the day.
So I think where the leadership comes from is interesting. It also can be where the massive block is, if I’m honest, you see organisational focus over and above system focus. You know I’m king of my castle running this organisation. I’ve managed the money, I haven’t got in trouble with the CQC and I don’t want to risk upsetting that. That can be a massive block.
I think the other element is we’ve not invested in general practice. I mean massively disproportionately, not invested in general practice and actually they’re one of the parts of the NHS that have shown enormous productivity gain. There’s been zero investment and seeing hugely more people compared with other elements of the NHS, but that’s now at breaking point and all over the country, people looking at wanting to hand back contracts. So there needs to be a new way of harnessing what I see as the amazing innovative leadership and agility of general practice. Along with some of the ability to hold financial risk and reward where the work happens, of the bigger organisations.
So I think you need to find a way through it locally and we can pick that up as a debate again later on. But my thing is both that system level, I actually think at a national level, but at a certainly at a system level and then down to a frontline team level, one of the things you’re about to hear me say is one of the success factors we see is when there is a single leadership agreed at the frontline team level.
I think one of the really important characteristics and shifts in leadership style that needs to happen here, is we stop going from a top-down hierarchical diktat that ‘this is what the widgets are tell us if you can deliver them next Wednesday’ to a much more progressive style of leadership, where teams are given the headspace, the leadership space and the resources to adapt for their local community to deliver success for them. That doesn’t mean I don’t think we should be measuring metrics I will come to that.
One of the things we’re seeing working really well is when you have systems coming together to really agree what is the integrated neighbourhood team model for their system. And then what are the design principles that they are all signing up to in terms of how they’re going to be delivered within their system? And when I say people coming together on this, I don’t mean a management meeting sitting with minutes on teams. I mean, going out and working with hundreds of people in the system and having a conversation about what success is going to look like.
Thank you for listening to this instalment. In Part 2, we discussed the critical success factors we have found from our work in supporting INT’s across the country.
