Implementing Innovation, Integration & Sustainability Dr Kate Fayers Consultant Diabetologist West Hants Community Diabetes Service Kate.fayers@southernhealth.nhs.uk
West Hampshire Approach INNOVATIO N INTEGR NTEGRATI TI ON ON SUST SUSTAI AINAB NAB IL ILITY ITY
Geared for success Leadership & Engagement INNOVATIO N Patients & Surgeries Front and Centre INTEG INTEGRATIO ATION Flex and Adapt SUSTAI SUST AINAB NAB IL ILITY ITY Constantly!
Geared for success Leadership & Engagement INNOVATIO N Patients & Surgeries Front and Centre INTEG INTEGRATION ATION Flex and Adapt SUST SUSTAI AINAB NAB Constantly! ILITY IL ITY
Leading change is not easy Elisabeth Kübler-Ross: http://www.ekrfoundation.org
Adoption and spread Diffusion Gap (Between first 16% and the rest of the population) Rogers E. Diffusion of innovations. New York: Free Press, 1983.
A clear vision Every little helps Be the best Vorsprung durch technik The most effective teams have a clear vision and can navigate priority thickets BMJ Qual Saf 2013 Culture and behaviour in the English NHS Mike West
Five Dysfunctions of a Team Inattention to results • Individual goals and status erode the focus on collective success • Avoiding interpersonal discomfort prevents team members from Avoidance of accountability holding each other to account • Lack of clarity or buy-in prevents team members sticking to the Lack of Commitment vision • A desire to preserve artificial harmony even when Fear of Conflict counterproductive • The fear of being vulnerable prevents the development of trust Absence of Trust across the team Five Dysfunctions of a Team: Patrick Lencioni 2002
Geared for success Leadership & Engagement INNOVATIO N Patients & Surgeries Front and Centre INTEGR NTEGRATIO TIO N Flex and Adapt SUSTAI SUST AINAB NAB Constantly! ILITY IL ITY
WEST HAMPSHIRE COMMUNITY DIABETES SERVICE Block contract across West Hants CCG 24,500 diabetes population (total: 500,000) 49 surgeries T1 & T2 Clinical care T1 & T2 education GP Outreach visits: PRACTICE MAKES PERFECT Staff: One WTE Consultant Band 7 Nurses (prescribers) Band 6 Nurses Dietitans Diabetes Educators
Our aim: West Hampshire Community Diabetes Service To ensure all people with diabetes have access to excellent skills and knowledge so they can achieve their Active participants individual goals and become active participants in their care whenever possible Achieve individual goals Access to excellent skills & knowledge
Our STP Data CCG HbA1c All Three CCG IAF Rating % pts Treatment achieving targets good % achieved Portsmouth 52.1 40.3 Requires Improvement Fareham & Gosport 53.7 40.6 Outstanding Isle of Wight 53.7 40 Requires Improvement South East Hampshire 56 41 Outstanding North Hampshire 56.8 34.5 Requires Improvement Southampton 56.9 36.3 Inadequate West Hampshire 58.5 36.7 Inadequate BP outcomes poor in WH, hence lower TT scores and rating…..linked to primary care processes?
National Diabetes Audit Data • When looking at HbA1c, BP and Cholesterol: – West Hants suffers from wide variation – Our CCG averages are lower than NHS England – Differences are not accounted for by elderly pop. ? RISK STRATIFICATION
Wonder is the beginning of Wisdom…. SOCRATES West Hampshire Integrated Specific Diabetes Outcome Measures INTRODUCING WISDOM SEPTEMBER 2017
Percentage 10.0 20.0 30.0 40.0 50.0 60.0 0.0 Forestside Medical Practice 50.5 Gratton Surgery 47.6 Chawton House Surgery 45.2 WISDOM practices - 2016/2017 percentage of patients achieving all three The Watercress Medical Group 43.8 The Arnewood Practice Milton Medical 43.4 Hedge End Medical Centre 42.5 North Baddesley Surgery 41.9 Park Surgery 40.8 Bursledon Surgery 40.7 Abbeywell Surgery 40.6 Twin Oaks Medical Centre 40.4 Forest Gate Surgery 40.2 NDA graph Totton Health Centre 39.8 Waterfront and Solent Surgery 39.1 St Mary's Surgery 39.1 treatment targets Testvale Surgery 39.0 Cornerways Medical Centre 38.7 Boyatt Wood Surgery 38.1 Whitchurch Surgery (Two Rivers) 38.1 The Andover Health Centre Medical… 36.6 Friargate Practice 36.4 Charlton Hill Surgery 35.1 Twyford Surgery 34.6 St Luke's Surgery 34.4 Dr SJF Goodison and Partners 34.1 New Milton Health Centre 33.7 Fordingbridge Surgery 33.3 Alresford Surgery 32.8 Stockbridge Surgery 32.7 Ringwood Medical Centre 32.6 Stokewood Surgery 29.6 Barton Surgery 21.3 40.8 West Meon Surgery Bishops Waltham Surgery Archers Practice The Fryern Surgery St Clements Partnership
How will WISDOM address variation ? Knowledge T2 Patient + Process Care Primary Care Clusters Increase no. of patients achieving 3TT
Our learning from outreach Knowledge vs Process • Each surgery has a bespoke set of processes • How do these vary and importantly are they related to outcomes? • What do you think? • For example: – When are patients recalled? – Do you have a practice nurse with an interest in Diabetes? – Who manages blood pressure (GP or PN)? – How do practice nurses and GPs communicate?
WISDOM: Our Aims Building • Quickly assembled a team September 17 CONSISTENCY • & Led by two GPs with a special interest CONFIDENCE • Identified core aims and messages • Light touch specialist consultant governance • Let autonomy drive improvement WISDOM Improving Changing CONVERSATIONS CARE
Our targets & why EMT: Early Missed Targets HbA1c stratification: Treatment Target Criteria – Green under 58 mmol/L HbA1c ≥ 58 ≤ 70 – Amber 58 to 70 Blood Pressure 140/80 -160/90 – Red over 70 Cholesterol Over 5 (not 75 as in QOF “target”) Each surgery pulls data using PRIMIS Diabetes.
Why AMBERS? • WISDOM project aims to identify patients with Early Missed Targets: – Prevent future complications – Easy medication changes – Managed within primary care (with support) – Integrates with the specialist community service
From Innovation to Implementation: in six months • Excellent practice engagement EMT: Early Missed Targets – 37/49 (Q3 16/17) 75% – 44/49 (Q1 17/18) 90% • Cluster feedback: Treatment Target Criteria – 92% “practice would change as a result of this HbA1c ≥ 58 ≤ 70 meeting.” • WISER (T2 ed refresher) – Blood Pressure 140/80 -160/90 65 patients – Content specific for refresher course – Cholesterol Over 5 8 sessions – Feedback 87.7% of patients would recommend the course
Geared for success Leadership & Engagement INNOVATIO N Patients & Surgeries Front and Centre INTEG INTEGRATION ATION SUSTAI SUST AINAB NAB Flex and Adapt IL ILITY ITY Constantly!
Sustainability: Marginal Gains Plan Quality Act See Improvement Do
Sustainability: Monitoring demand
Fail fast and learn faster Can you think of a situation where attempts to change something failed? What were the factors? What happened next? How long did that all take? Don Berwick
Culture eats strategy for breakfast Peter Drucker
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