Health is made at home, hospitals are for repairs

I’ve spent the past two days catching up with colleagues at the NHS Providers Conference in Liverpool. Here are some highlights.??

After a strong opening by Julian Hartley including the importance of an improvement methodology within NHS providers and how regulation needs to support innovation, which is particularly encouraging thinking of his next role, there was a session reflecting upon the Darzi diagnostic.?Rebecca Barry, Correspondent, ITV News described the three shocks that Lord Darzi had described hitting the NHS as:

“austerity, a calamitous top down reorganisation and the pandemic”?

Jacob Lant , CEO of National Voices highlighted that you were??-

Twice as likely to be waiting over a year if from a deprived group

He also made the very good point that while in the media and in Westminster the concern on GP access is same day urgent care, this is not what he is hearing from patients at all, or the charities representing them, and risks the NHS coming up with the wrong solution. He outlined that the message they are hearing is that those with long term conditions - who do of course make up the vast majority of GP visits - want excellent ongoing support, planned care and the ability to book in the future, not at the last minute.?

Dr Ify Okocha CEO at Oxleas NHS Foundation Trust was also very interesting. He painted a picture of the future and a vision of an NHS in 5 years, where waits are down and A&Es are calm, and how that relies on our strengthening home and community care.

He referenced Lord Nigel Crisp’s book “Health is made at home - hospitals are for repairs” and wondered whether many of us have read it.?

https://healthismadeathome.salus.global

I have read and enjoyed it, great perspective from someone who used to be CEO of the NHS, articulating a vision for the NHS to shift much more care into the home. Written ahead of the pandemic, tech-enablement would be an important addition for me, as the route to do this at scale.?

After the plenary we selected sessions and the best one I attended was on the HomeFirst work that has been led by the Leeds Health & Care Partnership - that has delivered impressive impact for Leeds residents.?

Moving from hospital to home is one of the three shifts the new government has committed to, and an area I am fascinated by personally, so it was great to hear a solid example of how that is being achieved in Leeds. This is, of course, a major issue across the country, as health and care systems are facing a range of challenges in the delivery of intermediate care due to rising demand, driven in part by an ageing population with increasing multiple long term health conditions.?

The SRO of HomeFirst is Phil Wood CEO, Leeds Teaching Hospital who kicked off the session. He described a difficult winter two years ago, tense conversations, and a big focus on discharge but entirely from the acute trust end, and that -?

"Wasn’t the way we wanted to think about things in Leeds”?

He continued that in April 22 -

"We decided we wanted to have a different view”?

The Partnership - which brings together health and care organisations in the city - commissioned Newton to conduct an initial review to help identify how the system could improve the delivery of intermediate care for the residents of Leeds. This demonstrated that whilst thousands of people from across Leeds were receiving great health and care, there were a number of major challenges in the system related to patient flow and the transfer of people into intermediate care. So they set out to transform the way that intermediate care is delivered in Leeds.

Phil said that the diagnostic was incredibly valuable as told them a great deal about the opportunity, for example that over 400 more people could be supported to recover at home.?

"That Leeds was a city that was using a lot of bed based care and buying more over the winter"

The diagnostic spurred action and the project was established.?It was important, he added, that it was driven by the shared improvement method across Leeds and enabling people to make improvements to their own work and service.?

"We were inspired by the diagnostic - it was compelling" Sam Prince, Executive Director of Operations?

The HomeFirst programme

The Programme Director, Megan Rowlands then took over and described how they set up the project. She explained it aims to achieve -

“a person-centred, home-first model of intermediate care that is joined up and promotes independence”.

It consists of five projects which focus on maximising independence and ensures that residents always achieve their best outcome. The work was led by the Partnership who appointed Megan as programme director, and was supported by Newton.?She outlined how they designed the programme -

The five projects being

• System Visibility & Active Leadership: making use of the wealth of data in the system to produce system and service level dashboards, while establishing the right cross-partner governance to use these for effective decision-making
• Active Recovery at Home: redesigning the home-based intermediate care offer, to maximise capacity and deliver the best outcomes for people accessing these services
• Enhanced Care at Home: transforming preventive services to avoid escalations in need with a specific focus on avoidable acute hospital admissions
• Rehab & Recovery Beds: transforming bed-based intermediate care to improve outcomes and minimise length of stay in short-term beds
• Transfers of Care: redesigning the discharge model to minimise discharge delays and ensure the system achieves the most independent outcomes for people leaving hospital

Single version of the truth?

This single version of the truth in the dashboard felt very central to the strong collaboration. We heard that before the HomeFirst programme, system partners in Leeds regularly met to discuss system performance, but the lack of a unified data source meant these meetings were often inefficient and unfocused. Each partner organisation produced a lot of data, but without a single version of the truth, efforts were duplicated, and trust was eroded. Leeds needed a way to consolidate their data and a leadership model to ensure decisions were evidence-based at every stage.

"We used our existing systems to bring together a single view to support us in decision making" Megan Rowlands, Programme Director??

The introduction of the system visibility dashboard addressed this need by bringing existing data into a single, regularly updated platform. This dashboard supports decision-making at all levels, providing patient-identifiable data for joint case management at the team level and highlighting areas needing additional support at the service and system levels. For the first time, heads of service from all health and care organisations in Leeds can effectively review system pressures and delays, allowing for timely, cross-organisational actions to relieve pressure before it escalate.

An example of it in practice was seeing the improvements in a range pathways such as acute days to discharge but increasing in community beds and could drill down to show the reason and take action?

“This single view was a real catalyst to collaboration” - Phil Wood?

In the case study write up of the programme (link below) other members of the team expand on how important it has been to joint working

Leeds HomeFirst Case Study

"What the dashboard has given us is one version of the truth so that we can actually focus on what we need to do for the people of Leeds to improve their outcomes and we're doing it together. Rather than having a culture where we don't necessarily trust each other, and we don't necessarily trust each other’s data. We've now got real agreement and consensus and can move forward, taking actions together collaboratively." -?Nicola Nicholson, Associate Director of Strategies and Programmes, West Yorkshire ICB

Outcomes:

The HomeFirst programme has clearly achieved a host of positive outcomes, from seasonal pressures on the acute hospital being reduced, to a reduction on the system’s reliance on long-term care. Some that jumped out of me were -

• 786 fewer adults admitted to hospital each year
• 421 more people going directly home after their stay in hospital each year
• 169 more people able to return home after their time in intermediate care, rather than a long-term bedded setting, each year
• A marked 8.2 day reduction in the average length of stay in short-term beds
• 31% reduction in length of stay for complex patients with no current reason to reside
• 522 additional people benefitting from reablement each year
• 33% decrease in readmission rates after receiving home-based reablement

Megan said that this performance translates to ￡23.7m per annum of equivalent financial benefit to the system.

“The beauty of HomeFirst is that it has brought people together through a partnership and TeamLeeds approach to look at all the key transitional points where people move from the community to hospital, from hospital to home, and from hospital to community care beds. It feels so much more joined-up now because we have had so much commitment to doing this as a system rather than individual organisations.” - Sam Prince, Executive Director of Operations, Leeds Community Healthcare NHS Trust

Genuine collaboration:??

The panel gave a genuine sense of working together in a true partnership, and being proud of what they had been able to achieve having delivered a new model of intermediate care within existing workforce, funding and organisational arrangements.?

Caroline Baria, the Director of Adults and Health at Leeds City Council provided some practical examples of this -

"We realised housing issues were a big part of delays, homelessness but also suitability, so there are two housing officers within the Transfers of Care hub team in the hospital"

Phil outlined that they did visits into other parts of care - from the Trust he visited care homes with his acute team, local government and community colleagues came into the hospital, it was important to really "walk in each other shoes". ?

"Everybody is now working together, so we're working in the hospital together with community and primary care colleagues and with social care to ensure that we've got a truly integrated way of person-centred support based on need."

Learning and tips for others

Sam Prince agreed in the need to really invest in the relationships and added that another point she would pass onto colleagues was that -

"You can’t run the system and change it at the same time on half an hour a week, this needs a proper team to deliver the change"?

She explained that they created a team pulled from all the organisations and

"We recognised where we had gaps and Newton helped provide support where we needed it and provided valuable project discipline"?

Caroline felt that the single view had been

“Instrumental in bringing us together and recognising that activity in one part has an adverse impact on another point and really empowering for our operational staff as could rapidly see impact and then wanted to share the learning”?

She added that teams were

"No longer waiting for gold command because we can see what needs doing and can go ahead and action. In fact, we didn’t have any gold escalation meetings last winter."?

Everyone felt that the benefits achieved in Leeds could be replicated in other settings, if teams did a proper diagnostic and were prepared to put the work into building relationships and wrapping services around peoples' needs with a Home First philosophy.

In terms of what's next, Sam said that the focus on delays has been so effective, they would now like to get into upstream intervention to stop deterioration?at the earliest point.

What are you most proud of

Jenny then asked the panel what they were most proud of. Megan said that before the project began they were receiving feedback from patients and Healthwatch that the patient experience wasn't good enough and was fragmented between care and health. To see this improve so much such that -

"90% patients agreed that their care was delivered by one team”?

Made her really proud, as did the response from staff

“We’ve had fantastic feedback from our staff about working in this way and we are really proud of this project.”

Caroline said she was really proud of how many more people were able to stay at home and that she never wanted to

"go back to a default to long term residential care when people had only gone in on a short term basis because there was no alternative"?

Phil said for him, it was the

"Demonstrable impact on flow in the hospital. Being stopped by one of our liver transplant surgeons to say we have rejected far fewer livers this year - this was the impact of HomeFirst"?

And finally,

"Rather than talk about health inequalities, it has been brilliant to see an impact on them."

Caroline added

"Working on delivering a programme with the scale and complexity of HomeFirst is never an easy task, and requires a high level of dedication, commitment and hard work, day-in, day-out from everyone involved. It has been fantastic therefore to see how through a collaborative and a real TeamLeeds approach with partners, we have seen leaders and staff across each of the projects really embrace the challenge and deliver some extremely positive results to improve and further support the delivery of intermediate care services across the city."

Conclusions

It struck me that fundamental to the success of the HomeFirst programme has been building on the culture and relationships across partners in the system; embedding a culture of collaborative decision making and service delivery. Central to this has been that single view.

As a result of the changes made the HomeFirst programme, more residents are achieving their best outcome whilst simultaneously relieving seasonal pressures on the acute and unlocking significant financial benefit within the system. I also thought it was important that the new ways of working had been designed, trialled, iterated and scaled by experts including frontline staff and operational managers from across the system, who were given the freedom to innovate and solve problems without escalation. Great work and I totted up that this was an extra 1,376 people able to stay in their own home, so far.

In The Rt. Hon. Wes Streeting MP keynote speech the following day, he highlighted Leeds as an example of excellence in the integration of social and health care services within the city, and it felt very appropriate to hear this great work recognised.?

Phil Wood

Samantha Prince

Caroline Baria

Megan Rowlands

Leeds City Council

Leeds Teaching Hospitals NHS Trust

Leeds Health and Care Partnership

Newton

NHS Providers