NHS West Kent Clinical Commissioning Group
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Leading the Implementation of Clinical Microsystems in Primary Care;
The West Kent CCG Experience
Gail Arnold
Chief Operating Officer
Dr Debbie Taylor
Clinical Lead for QI and
Clinical Microsystems
NHS West Kent Clinical Commissioning Group
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The next hour…..
• This session will explore the leadership challenge of
introducing clinical Microsystems to general practices
and partner organisations in West Kent.
• It will focus on the links to STPs in this programme of
work and its relevance to delivering Local Care in the
future.
• It will also look at some of the barriers to implementation
that were experienced and the tactics used to overcome
these.
• Finally it will give an overview of the range of
Microsystems completed in West Kent
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Where our journey began…
• In May 2013 Jonkoping, Sweden… and Esther opened
our eyes to the concept
• Reflected long and hard at home to find strategic fit with
what we had seen and our world in the NHS
• Challenges facing general practice and primary care
- recruitment, retention, finances, increasing demand
• Growing number of elderly frail patients and those with
multiple Long Term Conditions
• The challenge of co-ordinating care around a patient
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Mapping the Future 2013
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Patients at the centre
From all of this the CCG team decided that clinical microsystems was potentially a way forward
Who are supported by
the GP Cluster
Practice Support Team (Proactive Care)
Who are
supported by my GP
and the Practice team
Who are supported by
the Primary Care Hub (Reactive Care)
I am
supported
to stay healthy
by my
community
Pre
ve
ntio
n
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Health & Social Care Teams
Prevention
End of Life Care
LTC Management
Community Mental Health
Services
Frailty Services
Enhanced diagnostics
Timely Access to Consultant
Advice
Enhanced Medicines Optimisation
Service
Supporting Therapy Services
Integrated nursing Teams (delivering
care in surgery and patients home)
Ne
w P
rima
ry
Care
LOCAL CARE
In hospital care
Built on a Strong Bedrock of General Practice with the following characteristics
In A Suitable
Estate Sustainable
Supported By
Technology Efficient
Skilled
Workforce Accessible Timely Holistic
Patient
Centred
Population
Based
Healthcare
High
Performing
Recognition of
Deprivation
GMS
Element
Additional
Services
Item of
Service Fees
Incentive
Schemes
Estates
Management
QOF
Enhanced
Services
Recognition
of Homes
Financial Feed
A Vision for Local Care
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Presenting to the membership..
• Highly challenging of the proposal
• They did not share the Board’s vision of teams around
practices
• Questioned funding being spent on training microsystem
coaches which they felt should have been spent on
practices
• Struggling with the strategic context
• Did not necessarily want teams around practices
• Saw it as a diversion from the critical needs of practices
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However we pressed on….
…….. and in September 2014 send our first cohort of
trainee coaches to Dartmouth
Great teaching
International input and experience
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On return …..
• We had a team of coaches, but not practices to coach!
• Struggled to find practices to engage
• Our distance training was continuing but we were not
getting going with coaching to put our skills into practice
• It was easier to get other system stakeholders on board
than it was to convince our GP practices
• Practices did not want our agenda..
NHS West Kent Clinical Commissioning Group
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WEST KENT Challenges 1
• Initial lack of experience
and confidence
• Interpreting US and
international examples to
fit with NHS
• Whose agenda were we
aiming at?
• Top down or bottom up?
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WEST KENT Challenges 2 • Interpreting Secondary
Care examples and
translating them to
Primary Care
• Suspicion in Primary Care
- we don’t need coaching
we are GPs! We don’t
want this system.
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WEST KENT Challenges 3 • Timing difficulty in
Primary Care in NHS with
winter pressures - time to
attend meetings
• Primary Care GPs self
employed - difficulty
releasing staff to attend
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WEST KENT Challenges 4
• Time to attend
meetings/ cancelling
due to work
commitments
pressure eg CQC
inspections etc.
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Challenges 5
• We don’t need help with
quality improvements we
have done 6 sigma and
other leadership models
• Can’t we have a whole
day session to fit with our
work?
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So we reflected hard on what we
were hearing
• What options did we have?
• How might we overcome some of the obstacles?
• Was it using microsystems to underpin introduction of our
strategic vision of models of care?
• How could we change the way general practice viewed this?
• Our coaches attended the Sheffield MCA which reinvigorated
us!!
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This is the approach we took
• We persuaded 5 practices to work with our first group of coaches
• In parallel we embarked on a programme of visits to all our 60 practices
• We stood in their shoes
• We tried to look at it their way, from their perspective, faced with their difficulties and challenges
• We changed our behaviours as a team to be ones which focused on how we could support our practices
• We met them where they were
• AND WE LISTENED VERY HARD
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What did we learn from this reflection
• Life in general practice is hard
• General practices are independent businesses
and many were struggling
• We have no authority, we can only influence
• It was pointless going to practices to implement our vision for a new model of care when their own practice issues didn’t let them see beyond that
• Time is money
• Our wish to work with them implied criticism of their performance/achievements
• We were the CCG, after all! They didn’t want our staff in their world.
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So we had a rethink..
• We changed the offering, their agenda not ours.
• We offered a microsystem as practical help for whatever
the practice wanted to work on
• All roads lead to quality improvement - framing
• We flexed our hours to fit with their day, sometimes we
coached early in the morning and sometimes late in the
day
• We created a budget in the CCG to support QI in primary
care (clinical microsystems) and we offered a
reimbursement package for backfill
• We took the burden in the CCG of producing packs,
posters, data charts etc.
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• We recognised that to practices this was an abstract concept and we had to make it real and personal for them
• We acknowledged that if we were to get traction and keep a practice interested we had to invest in lots of personal discussion with their leaders
• We became good at global aims and specific aims
• We are masters now at getting staff into the room and moving them to a shortlist of specific aims in no more than 1.5hrs (1 meeting)
• We’ve accepted the authority given to us by the CCG to go out and do this stuff
• We challenged our GP board members to use a microsystem in their practice
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We made a film to promote our work
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The clinical engagement
challenge…. 1
• We knew we needed our primary care clinicians,
especially our GPs, to support our work
• We knew that their time was precious
• We knew they were struggling with workload
• Time in microsystems was work stacking up
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The clinical engagement
challenge…. 2
• We knew they found it hard to share areas for
improvement – “we don’t need a clinical microsystem,
everything is good here”.
• Involving patients was a challenging concept for some
• Some practice managers felt threatened
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WEST KENT Success 1
• Lack of experience- We
gained it perseverance and
practice!
• Differences in NHS- We
made it fit!
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WEST KENT Success 2 • Secondary vs Primary Care-
We adapted models to fit!
• Suspicion we don’t need
coaching - we had champions
who shared successes, and
explained we were talking
about quality improvement.
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WEST KENT Success 3
• Winter Pressure – We
were patient and waited
• Self employed GPs
difficulty releasing staff-
We gave back fill
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Success 4 • Suspicions about spending money to train
coaches - We demonstrated that it was
more economical than sending people up
to London on day courses
• Time to attend meetings and cancelling -
We showed the benefits and how it could
save time and money in the long run, we
were flexible.
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WEST KENT Success 5 • We don’t need microsystems
coaching - we showed that
sustainable changes can be
made with this model
• Can’t we just have a day
course to get it over with - we
demonstrated that there is a
good reason coaching
happens in chunks with time
for reflection
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Connections
At the heart of everything its
about relationships first …
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Sharing Good
Practice Town Hall Event
AGM/PLT CCG
Workshops
Sharing good
Practice
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Feedback
“ “There is no other
environment in my practice
where I could safely have
said the things I have”
“We all had different
ideas about what the
process was”
“We’re amazed how much
you moved our practice
on in 1.25 hours”
“We haven’t had a whole
practice meeting like this
ever”
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Feedback
“I had no idea
the CCG could
help us like this
– I never
thought to ask”
“We have
never been
trusted to
come up with a
solution for
anything”
“Its been good to
be challenged
about why we do
things the way we
do”
I’m not very good at
data so I’ve never set
things out and looked
at them in this way”
“I don’t know what
you’ve done to my
team – I’ve never seen
them so enthusiastic”
“I can see lots of
ways we could
use these tools”
NHS West Kent Clinical Commissioning Group
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WEST KENT Where are we now?
• We’ve trained 4 cohorts of coaches (14 )
• First 2 in Boston, following 2 in Sheffield
• Cohort 5 are in training now in Sheffield (4)
• We’ve appointed a GP clinical advisor
• We have a recurrently identified budget for this work
• 26 microsystems successfully initiated
• Using the methodology widely
• We’ve learned a lot from the 3 that failed
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Emotions
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Our vision was right, the timing needed to catch up
Our practices needed to want to participate
This is not in itself a fix for problem practices but it
is an answer to challenges in practices
Communication is key especially combined with
authority to act
Money is important …. But it still doesn’t replace
time
NHS West Kent Clinical Commissioning Group
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1. We have just introduced clusters in West Kent made up
of practices and community teams
2. Coaches have been attached to each cluster
3. We are branching out into non-practice environments
4. We are using the tools we have learned repeatedly in
practices
5. The skills from microsystems are percolating across our
CCG organisation
6. We continue to train more coaches with a view to
completing a microsystem in every practice
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10Top Tips from our experiences
1. Good Leadership
2. Champion within our organisation
3. Regular coaching support groups
4. Co-coaching
5. Select and connect to keen Practices
6. Avoid selecting practices in difficulty
7. Have clear coaching agreements
8. Develop champions
9. Be a strong cohesive coaching group
10. Share successes and good practices
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Some principles for leading change in a
complex adaptive system
• Think like a farmer, not an engineer
• Continually reframe the narrative to attract new
supporters
• Create a social movement
• Don’t over-plan – outcomes are not predictable
• Establish boundaries, create simple rules
• Replace directives and regulations with common
purpose, values, principles
• Dump the concept of ‘resistance to change’ – it’s
negative and draining
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Useful reflections from others
…….spreading innovations…..is essentially a social process that
hinges on effective person-to-person communication rather than
technological solutions or indeed the use of incentives and
penalties
(Gawande 2013)
. …people follow the example of those they know and trust
………there is no alternative to creating time and opportunities for
credible leaders and innovators to offer time and support to those
seeking to bring about improvements in care.
(Reforming the NHS From Within. Chris Ham, Kings Fund, 2014)
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The Seven of Pentacles 1
Under a sky the colour of pea soup
she is looking at her work growing
away there
actively, thickly like grapevines or
pole beans
as things grow in the real world,
slowly enough.
If you tend them properly, if you
mulch, if you water,
If you provide birds that eat insects
a home and winter food,
If the sun shines and you pick off
caterpillars,
If the praying mantis comes and the
ladybugs and the bees,
then the plants flourish, but at their
own internal clock.
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The Seven of Pentacles 2
Connections are made slowly,
sometimes they grow underground.
You cannot tell always by looking
what is happening.
More than half the tree is spread out
in the soil under your feet.
Penetrate quietly as the earthworm
that blows no trumpet.
Fight persistently as the creeper that
brings down the tree.
Spread like the squash plant that
overruns the garden.
Gnaw in the dark and use the sun to
make sugar.
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The Seven of Pentacles 3
Weave real connections, create
real nodes, build real houses.
live a life you can endure: Make
love that is loving.
keep tangling and interweaving
and taking more in,
a thicket and bramble wilderness
to the outside but to us
Interconnected with rabbit runs
and burrows and lairs.
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The Seven of Pentacles 4
Live as if you liked yourself, and it may
happen:
reach out, keep reaching out, keep
bringing in.
This is how we are going to live for a
long time: not always,
for every gardener knows that after
digging after planting,
after the long season of tending and
growth, the harvest comes.
Marge Piercy
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