Value-Adding Approach to Lot 6 Service Delivery

Through supporting major change programmes in health and care systems nationally and particularly across the south of England, we have developed a diverse ‘Transformation and Consultancy’ service comprising the full range of skills and expertise an ICS may need. We have160 transformation and change consultants and 250 care analysts, as well as niche expertise, thought leadership and capacity from partners such as PA Consulting, Lightfoot, and The Dartmouth Institute. Our capability and experience covers the establishment of new forms of system leadership, developing the insight and understanding needed to design the right interventions, engaging and involving key stakeholders through interactive and genuine engagement processes, designing and implementing new models of care that promote health and wellbeing, and transitioning change and ongoing oversight into ‘business as usual’ processes. Systems gain value from our ability to provide an end-to-end transformation service: 

  • Through our ‘INSIGHTS’ business intelligence service and population health analytics tools, we can identify opportunities and alter the way information is provided to front line care providers and system leaders to ensure well-informed decision-making. 
  • Our digital transformation and IT services deliver the enabling infrastructure for effective population health management approaches and are national leaders in digital transformation and system interoperability, having led five of the country’s most successful programmes in Hampshire, Gloucestershire, Oxfordshire, Buckinghamshire and the Bristol area. 
  • Our transformation experts possess strong change management skills allied with niche expertise in areas such as patient activation, interventions to address the wider determinants of health and promote health and wellbeing, management of chronic conditions, primary community and acute care redesign, innovative approaches to mental health transformation, and the efficient delivery of urgent care systems. Their experience spans the traditional boundaries of local authority, NHS and third sector organisations which enables us to maximise the combined impact of resources within a community, as demonstrated in the ‘Smokefree South West programme we delivered to reduce smoking prevalence from 26% to 17%. 
  • Through our organisational expertise and experience in the development of new contractual forms and the creation of aligned incentives, we are able to ensure the interventions we support are embedded in business as usual processes.
  • The breadth of our capability and our supply chain of expert partners allow us to provide a ‘one stop shop’ service for an ICS, reducing support overheads and simplifying accountability for delivery.  

The case study that follows this response describes the wide-ranging transformation support we are providing for the Frimley health and care system, supporting leaders to plan, manage and evaluate change, develop person-centred care models, drive digital integration, and pilot innovative approaches to self-care. While we have the ability to produce credible and thought-provoking reports and plans, we invest most energy in actually delivering and embedding change in the fabric of a local system. We are passionate about creating beneficial change at the front line. We take accountability for delivering transformation outcomes, and we optimise sustainability by ensuring that local care teams are fully engaged in the process. We have an appetite for sharing the pain and pressure of change, which helps build commitment, motivation and resilience in the individuals delivering it. 

Extended Case Study: Supporting Transformation and Change in the Frimley Health and Care System

The Frimley health and care system is one of nine systems given the green light to fast-track health and care improvements for its population of 750,000 residents in Surrey, North East Hampshire and East Berkshire. Since the first stages of development, SCW has supported system leaders to model, plan, and deliver numerous initiatives to transform health and care provision in the region, several of which we reference below. SCW continues to work closely with senior leaders in Frimley to meet the evolving requirements of the system, as it develops to become a fully-fledged Integrated Care System (ICS).

 

SCW worked with our partner Rubicon Health Consulting to develop a whole-system finance and activity model that showed the impact of proposed new care models versus a ‘do nothing’ baseline. We analysed data from acute, community, mental and continuing healthcare; primary care; NHS specialised services; CCGs; NHS commissioned adult social care; and other Local Authority sources. We showed the impact of change from different perspectives (taxpayers, commissioners, NHS health providers, and social care providers) to support system-wide engagement and planning. SCW used the model to support multiple other health and care systems and it was adopted by the NHSE New Care Models team for national use. 

Using the RightCare approach, we developed a ‘variation heat map’ for the whole system that identified unwarranted variation in stroke, heart disease, renal, MSK/trauma, neurology and respiratory pathways and gave a whole-system view of opportunities to improve outcomes and costs. In these priority areas, we subsequently completed deep dive analyses to inform the Frimley ‘unwarranted variation’ workstream, to enable it to consider the most appropriate interventions and service adaptations to realise the potential benefits.

We have supported the development of integrated care hubs in North East Hampshire and Farnham. As part of our support for integrated care, we have developed an interactive multi-layered mapping tool that allows system partners to visualise population demographic data alongside current and potential configurations of primary and community care services. The map layers include service site locations (GP practices, hospitals, pharmacies, care homes and potential new hub locations); disease prevalence by GP practice and by geographic area; hospital activity (inpatients, outpatients, A&E) by CCG and by GP practice; travel times and accessibility (private car and public transport); and travel-based catchment areas for provider sites.

We are facilitating evidence-based decision making by supporting Frimley to monitor performance and the impact of planned transformation and change initiatives across the whole system. This includes developing an Integrated System Dashboard to link service delivery, system interventions and transformational changes to system objectives and desired outcomes and, building on our previous development of Vanguard dashboards, we are developing a Programme Dashboard to monitor and evaluate delivery of transformation projects in the region.

While we recognise that digital transformation is the focus of Lot 2A and Lot 2B, this is a critical enabling aspect of wider transformation and change in the Frimley system. As a result, we are coordinating a programme of co-development between local health and social care organisations to finalise a Local Digital Roadmap for the region, bringing together multiple legacy plans to create a single coherent strategy. We have also played a leading role in developing the Connected Care shared care record to enable the sharing of information across 98 GP practices and 27 health and care partners in the system.

In conjunction with our partners Microsoft, System C and Graphnet, we are conducting a pilot to collect lifestyle data from wearable technologies and upload it into care records. This innovative project draws upon our expertise in both social marketing and digital transformation and allow clinicians to review and interpret wellness information alongside traditional health and care data and identify opportunities to promote behaviour change in participants and support an increased focus on self-care.

SCW and Rubicon were engaged by the NEH&F programme team to develop a whole health and social care system activity and financial model to support the Vanguard. The model and associated support they have delivered is excellent. It allows us to understand in considerable detail the impact of ‘doing nothing’ on the affordability of health and care across our local system. The model also clearly demonstrates the potential impact of changes under our new models of care in a series of ‘change scenarios’. We have used the model extensively to guide development of our system-wide plans and will use the modelling as a key input to the development of our STP.

Roshan Patel, Chief Finance Officer, North East Hampshire and Farnham CCG

The support which SCW provides has been critical to the development of our Integrated Care System. An example is SCW’s support to the development and delivery of the Connected Care shared care record programme. The development of a shared care record is a central building block to the overall development of our ICS – and to the realisation of our transformation plans for the system - and SCW’s support to us on this programme has been excellent.

Nigel Foster, Director of Finance and IM&T, Frimley Health NHS Foundation Trust

How We Work with Partners in Lot 6

Many of our carefully selected partners are transformation and change specialists. We particularly highlight the Dartmouth Institute, which has co-developed the Place Based Care Programme for New Model of Care Vanguards and are currently supporting SCW on a programme to integrate NHSE and NHSI functions in the south of England. Dartmouth brings a range of experience, knowledge and clinical credibility from working in care systems around the world, with a particular strength in understanding and managing unwarranted variation. Other specialist partners we work with have expertise in risk stratification and advanced analytics (Johns Hopkins University, Milliman), specialist change management techniques (PA Consulting), system modelling (Rubicon) digital transformation and interoperability (Cerner, Graphnet), primary care redesign (Scott McKenzie), and organisational development across traditional NHS boundaries (Worklife Company).  We also work with large-scale consultancies including Deloitte and PwC on national programmes such as the National QIPP Delivery Programme with/for NHSE. This extensive range of partners means SCW can draw upon critical insight, experience and capacity to support systems to design and deliver new models of care, increasing the opportunity for learning from others and maximising the value of their investment in these services.

 

Case Studies

As part of a major service review, Somerset CCG tasked our GIS team to complete a systematic analysis of how proposals to centralise stroke services would impact the whole population of Somerset. We applied our sophisticated GIS mapping and analytics methodology to provide critical evidence that directly improved service provision for stroke patients across an area covering 1,330 square miles. Mapping enabled stakeholders to visualise travel time analysis for emergency vehicles and private and public transport options, to identify the implications of change. The critical evidence we produced informed Somerset CCGs future planning process, and ultimately led to the decision to retain both stroke services in the county.

The redesign of pathology services across Bristol, North Somerset and South Gloucestershire was a particularly challenging change programme where we demonstrated the value of clinical champions. Launched at a time when there was a pre-existing inquiry into the services at one of the providers and when relationships between the clinical teams and with sections of the public were difficult, there was significant unease amongst local councillors. Closely supported by SCW, the clinical champions played a critical role in explaining what pathology services are, how they operate and why reconfiguration would enable the service to operate more effectively. This included the hosting of visits into the department to bring to life the way services operated and could be improved. 

For the public and councillors, the focus was on providing reassurance around the accessibility and quality of services. For pathology staff the implications in terms of their job security, place of work and career progression were also important. The champions led from the front, highlighting the need for and opportunity of change, challenging misconceptions and mistruths that existed and supporting those who were anxious or concerned. Throughout the process, SCW supported the champions by co-creating engagement materials and providing the personal support and encouragement they needed to fulfil their role. SCW colleagues involved in the process have just been invited to an event celebrating the opening of the new service and demonstrating the degree to which they operated as part of a single programme team.

Operating as an integrated system is not easy. There are statutory, policy, procedural, logistical, financial and behavioural issues that must be overcome and system leaders must develop effective solutions for navigating a course through these.  A further enabler of successful system leadership is the generation of trust between leaders and organisations. Trust is essential to enable the parties jointly to identify the existing behaviours, systems and processes that will assist them in their drive towards integrated working and those that must be discarded and replaced. In this context, our approach begins by working with senior leaders in the partner organisations to establish relationships and ways of working which generate increased trust. When operating as a system, individuals and organisations cannot rely solely on the authority provided through hierarchy, instead they must demonstrate through words and actions their commitment to shared goals. We support health and care systems to develop trust in three stages.

  • First, we support partners to agree the ground rules and objectives for collaboration. During this stage, we support investment in leadership development programmes, creation of new teams and the sharing of information. Due to the embryonic nature of the relationships and potentially limited levels of trust, decision-making at this stage requires a sound evidence base. SCW support this stage using our analytical teams and in particular our Geographic Information System (GIS) mapping solution that presents information such as travel times and patient flows in a graphical format, enabling easy visualisation of the findings. 
  • In stage two, we support partners to develop a deeper understanding and empathy for the concerns of others by facilitating activities that explore differences in beliefs, perspectives and expectations. This helps to create a shared understanding and improves the ownership of the solutions that are developed.
  • In the third stage, we support stakeholders to operate in a collaborative way to drive decision-making and action, by working together to diagnose and solve the challenges they face. This can involve looking into a specific issue and using a process such as De Bono’s ‘Thinking Hats’ to reframe perceptions and alter traditional positions.

By supporting the investment in the generation of trust between stakeholders and organisations, SCW helps system leaders to operate with the behaviours and generate an environment that is conducive to supporting successful transformation. Having established trust, leaders can implement and operate governance arrangements that drive system working. For example, in Bristol, North Somerset and South Gloucestershire, our teams helped create and facilitate a multi-organisational system leadership model that led to the collaborative reconfiguration of five major services between local providers and three commissioning organisations.

SCW is experienced in using the RightCare Opportunity Tool. We have built our own extended version building on the information contained in the NHS RightCare packs as well as SUS data to enable customers to understand the breadth of opportunity available to them and the areas where greater focus may be required. The tool uses bar charts and trend charts to help interpret variations between similar organisations and to allow the customer to choose specific areas for deep dive. This tool is available internally to all analysts and we have so far produced customer-specific versions of it for several STP areas in the south of England. 

SCW analysts provide further insight for customers by drawing on local knowledge to help stakeholders interpret results and understand any underlying data quality issues and the affect this might have. For example, GP practices across Somerset do not use QOF (Quality and Outcomes Framework), which affects referral indicators. We also provide advice and supporting information from other data sources (such as PH Fingertips, QOF, National Diabetes Audit or local returns) to help customers develop a UV narrative and to fully understand the opportunities available. To broaden analyses further, our teams can access national data and use it to identify the areas of greatest opportunity following a set methodology. For example, for NEW Devon, Oxfordshire, Surrey Heath, and NE Hants & Farnham CCGs, we forecast activity and cost variances if these organisations performed the same activity level in the same Healthcare Resource Groups as the best 5 CCGs in the Right Care ‘Similar 10 Peer CCGs’ comparator group.

SCW delivers ‘Where to Look’ prioritisation workshops with key stakeholders. We have designed these to engage key stakeholders from across the system to build effective partnerships, explore the opportunities that tackling UV presents, and to build consensus on the key areas of opportunity in the system. 

SCW led a prioritisation workshop for the Somerset system. Participants were divided into several cross organisation/patient groups and each identified their top three opportunities from the Commissioning for Value packs. Groups presented back their conclusions and rationale, we identified synergies, and then reached consensus to focus on diabetes, hypertension, respiratory, falls and neurology. In a current mental health workforce project, we have worked with stakeholders to develop a weighted prioritisation matrix in stages, by using stakeholder input to develop the prioritisation criteria, gathering “mean” weightings for the level of priority each criterion should hold, and then using the prioritisation matrix to objectively rank each work package. Where the group is unable to reach a consensus, we would support clinical leads to present the options through the appropriate governance and escalation route for ratification/decision (e.g. RightCare Steering Group, STP workstream board, CFO board).

We encourage the prioritisation of emerging ideas both ‘in the room’ as part of these optimal design workshops to capitalise on stakeholder engagement and buy in, and ‘outside the room’, testing the rigour of the ideas stakeholders generate for realising the opportunities so that the right solutions are pursued and the value and benefits can be realised. 

In the Somerset example above, SCW supported the system to apply an additional dimension to prioritisation to ensure that both quick wins and full system-wide transformation projects were prioritised objectively. In a system under significant  financial challenge, where there was a tendency to focus on quick wins, we aligned ‘How to Change’ with the NHSE 100-day challenge and NHSI 90-day rapid improvement approaches, to balance immediate impact with the need to adopt a rigorous and energised approach to wider change.

When exploring key lines of enquiry, SCW runs a comprehensive review of current best practice for each area of opportunity. Our researchers seek out good practice, optimum pathways, case studies with evidence of impact, and insight from other health and care systems locally, nationally and internationally. Their research includes academic journals and online resources, clinical experts and strategic clinical networks, AHSNs, National Programmes of Care, NICE, Fab Academy, Kings Fund, RightCare case studies, Royal Colleges, Map of Medicine, the third sector, and SCW partners. We summarise research findings and case studies for stakeholders, presenting opportunities, solutions, impacts and potential benefits we identify, aligned to local opportunities and priorities. We create strong visual summaries to increase impact and accessibility to the findings. We additionally reference insights that emerge from our partner, Dartmouth. Global leaders in understanding and addressing variation, their researchers have been working in this space for decades, making variation visible to clinicians, researchers, systems leaders, and policy makers in the U.S. and around the world. Dartmouth continue to host and attend seminars on these topics with global healthcare leaders, giving them (and SCW) continual access to emerging thinking and practice.

SCW works with stakeholders to develop clear, simple business cases that focus on how proposed changes will address the identified issues. We use logic models to present the case for change, linking cause and effect to the optimum outcomes, clearly demonstrating the health and financial benefits of change.  Based on the key steps of identifying ‘Where to Look’ through data analysis and interpretation, followed by stakeholder engagement to identify ‘What to Change’, the business case will present a clear and compelling narrative of ‘How to Change’ that sets out the roadmap, timetable, and future impact on the population. The SCW team work with system leaders to develop a clear understanding of the decision points, processes and bodies from which sign off is required in the completion of the business case to enable a smooth pathway to final sign off in a timely fashion.

Stakeholder engagement is critical to the development of a successful business case. We vary our approach to suit the audience and business case in question, using system-wide stakeholder events, organisation-specific events, group engagement with clinical teams, and 1-2-1 conversations with key individuals. We jointly consider and document the impact of changes on the workforce and estates structures by leading workforce analysis and financial/contract modelling programmes to increase certainty in the costs and benefits of the change, to test the logic of the business case, and to develop a compelling narrative for change. 

We have employed these steps and processes to support business case development for numerous health and care systems. For example, the North Somerset Maternity and Gynaecology review. Following analysis of activity and outcome data, patient feedback and clinician input, we facilitated a clear, focussed stakeholder discussion on the risks presented by current service configurations and the short, medium and long-term benefits of changes. The viability assessment was based on a common understanding of the outcomes required, and the issues and opportunities defined in a detailed options appraisal, which set out the costs and benefits of each option. These elements contributed to a health-system-wide case for change and move from outline to Full Business Case.

As part of our offer, our Clinical Effectiveness Team co-develops evidence-based clinical policies and pathways with care systems, to optimise treatment thresholds and minimise procedures of limited clinical and cost effectiveness, allowing funds to be re-invested in services with better outcomes. Challenging non-compliant activity of threshold dependent procedures has also led to the delivery of substantial QIPP savings. 

For example, SCW led a review of the Thames Valley CCGs’ assisted conception policy, resulting in policy improvements that saved an estimated £4.7m per annum compared to implementing the NICE CG156 Fertility recommendations in full. Based on our expertise in this area, NHS England commissioned SCW to lead development of an end-to-end best practice Clinical Policy Commissioning Toolkit and a Benchmarking Tool that enables commissioners to benchmark themselves against their RightCare peers and all other CCGs, in order to identify opportunities for detailed review, policy development and decommissioning.

To ensure effectiveness for care systems, we support CCGs to identify key decision-making criteria that support objective prioritisation. For example, co-designing a RightCare decision tree for Somerset. The decision tree incorporated key criteria of health outcomes, cost, impact and alignment with system priorities, underpinned by a quality impact assessment tool (used for all STP projects) to aid decision-making on more challenging issues, where the financial argument is compelling (in a financially challenged system) but the impact on health outcomes could potentially be negative for a small sector of the population.

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