Accelerating Pathway Redesign through System Leadership

Project Aim

Leaders of the health economy in Buckinghamshire identified a need both for a step change in the method of delivery of health, and a cultural shift in the way that organisations work together to deliver improvements and savings.  This report considers the final impact of work carried out in Buckinghamshire across the health economy in the period September 2012 to June 2013.  It reports on the work carried out, and makes recommendations for follow up activity to continue with the intended system changes, build relationships across organizational and sectoral boundaries and use a suite of improvement tools and methods which have been taught to staff locally.

Participation from the health economy included the two CCGs, Aylesbury Vale and Chiltern, the local acute Trust which also provides community services, the mental health Trust, a number of different providers of Out Of Hours care including the ambulance Trust, the local hospice; and a number of different representatives of the local authority.  Public health, education, police and housing were out of the scope of this project.

 This covered the following:

  • General recommendations to continue the work in Buckinghamshire
  • Background to the project
  • A description of the activities and outcomes of the three workstreams
  • Learning points from the Programme
  • Conclusions

Recommendations to the Buckinghamshire CCGs

In relation to the work on Unplanned Care, the challenge for the future will be to maintain the regular meetings, to complete tasks between meetings and to continue to set and monitor progress towards achieving agreed goals.

The detailed work carried out to date on the Out of Hours end-to-end pathway should form the basis for a new payment by results contract in Buckinghamshire. This should deliver the desired and agreed future state for the service.

Work is required locally to improve complex cross-organisational meetings.  A protocol is needed to ensure that meetings are scheduled sufficiently far in advance to ensure the right people are in attendance; that people then attend the meetings; that the agendas reflect the business appropriately and that meetings are conducted to maximise the value of face to face participation.  Time spent in addressing this issue would improve the productivity of the meetings which would in turn improve attendance, participation and the delivery of outcomes. A “Team Charter” was agreed at an early stage in the Pathway Acceleration Programme but it needs to be adopted and embedded in all partner organisations in the Bucks health care system.

Locality based practice manager meetings should be encouraged to foster the sharing and spread of best practice, with active support from the GP community.  The locally owned innovation which characterises the best practices should be transmitted as widely as possible, with GP champions who work to overcome resistance to change.

As regards the aim to create more headroom for commissioning activities: 

  • In order to create increased capacity for GPs, it is necessary to create head room further downstream by changing working practices in the non-clinical team.  This extra capacity then needs to be used to free up the time of GPs by passing some of their work to other members of staff. 
  • A major contributory factor to practice inefficiency is noise and interruptions.  Time needs to be spent thinking about where and when is the best place and time for specific tasks to minimise unnecessary noise and interruptions.  This includes giving the Practice Manager and Deputy Practice Manager protected time to complete key tasks such as forward planning of appointments, budget management and other more complex activities.  
  • Each GP needs to conduct a rigorous  “Day in the Life Of”(DILO) exercise to determine which tasks could be performed by others, what in their own actions are driving the behaviours of patients in ways that impact negatively on their time and what technologies could be deployed to save them time.  While they may not wish to implement all the identified possible changes, at least they would gain a sense of potential capacity for release and potential quick wins which work for them.

Finally, a number of overall learning points are included in this report in relation to leadership; working in silos and making assumptions; the benefits of involving all the relevant people; benchmarking best practice; the use of data; and following a structured process for improvement and using the right tools.  These issues all relate to the culture which is being established in the two CCGs.  Because the work on the Pathway Acceleration Programme was carried out in the very first months of the CCGs’ existence, these broader issues may prove to be a helpful diagnostic in terms of changes to culture and working practices over the next few years.  We recommend their adoption as some of the building blocks for developing an innovation and improvement orientation throughout the staff of both CCGs.

Background to the project and project summary

Leaders of the health economy in Buckinghamshire identified a need both for a step change in the method of delivery of health, and a cultural shift in the way that organisations work together to deliver improvements and savings.  Moreover, it is also accepted that in order to make this step change, it is necessary to both redesign processes and engage with stakeholders in these processes.

The aim of the Pathway Acceleration Programme was to utilise the pathway redesign expertise of Unipart Expert Practices (UEP), in a project designed with, and supported by, Thames Valley Health Innovation and Education Cluster (HIEC), to create capacity and capability within the Buckinghamshire Health Economy as a means to delivering QIPP savings through a step change in service delivery.

 After considerable internal discussion, three pieces of work were finally agreed in order to deliver these aims:

  • The InPACT Board would develop a Comm Cell for unplanned care which would map a full end-to-end pathway and be a live example of the whole system sharing performance information in a live time visual way. The focus of this work was across the whole of the Buckinghamshire health and care economy.
  • The new Out of Hours (OOH) contractual relationship would be reviewed from the perspective of the internal and external customers (patients) to see whether or not it was able to deliver the expected benefits and, if not, to get the contract working properly. The focus of this work was the two CCGs working together to deliver service improvement for the benefit of patients.
  • The Southern locality in Chiltern CCG identified inefficient processes at practice level in relation to a number of core processes. The aim of this work stream was to create head room for GPs to enable them to find time for their new system responsibilities.  The focus of this work was at individual practice level, and also sharing learning at a locality level.

In addition to delivering specific changes in relation to these areas of activity, the Pathway Acceleration Programme aimed to deliver a cultural change in the ways that people work.  The intention was that, by working at three different levels within and without the CCGs, connections and relationships would be identified and developed between the different workstreams, which would link learning both horizontally and vertically.  The hope was that this learning would form important cross-fertilisations between the different pieces of work.


For a summary of the report: HIEC summary PATHWAY ACCELERATION Programme eversion


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