The Evolution of Care Models: The Case For Change
The purpose of the Whole Systems programme is to change the care and support that people receive so that they are empowered to lead independent and fulfilling lives as active members of their communities. In this chapter, we examine how people who use services and their carers can come together with professionals and the voluntary sector to design new models of care, and the practical steps required to translate their aspirations into realistic proposals.
There are many excellent examples of high-quality care provided by the NHS and adult social-care in North West London. North West London has opened up new frontiers of innovation and possesses professionals who are passionate about delivering the highest quality of care. Chapter 2: Vision and Case for Change, describes many of our successful integration initiatives to date. Nonetheless, the basic structures—and the care models—of the health and care systems have remained largely unchanged since the founding of the welfare state in the middle of the 20th century. Indeed, as the design for a new national health service was debated in 1946, it was explicitly decided that too much change in care would be a bad thing, and efforts were made to secure a particular model of care and institutional arrangements.
However, like elsewhere in the country, at their core, care models have remained largely unchanged. The health system remains primarily structured around large hospitals which absorb the largest single share of the budget, with local GPs and local councils addressing routine needs and acting as "gatekeepers” to specialist care. Secondary, mental-health services and community services are organised into separate structures too. Different operational processes, funding systems, information flows and cultural and behavioural norms have developed in this fragmented economy of provision. As a result, the basic structure of care has remained unaltered, even as the management and commissioning structures of the NHS have been repeatedly reformed and restructured.
Yet both the needs and the expectations of the population have changed markedly over time. At the time the NHS was founded, it was designed to meet needs of routine primary medical care and episodic illnesses and accidents. Today, more than 7 million people nationally "have long-term conditions”, frequently having more than one condition. This means that individual care needs have become more complicated – successful management of long-term conditions requires joined-up, generalist medical skills, supported by specialist input (and sometimes specialist management), continuity of care and appropriate diagnostics and often social-care support too. In a fragmented system, meeting these needs to the satisfaction of people who use services and the professional fulfillment of those that provide them has become ever harder.
Care has continued to change and evolve even as care models have not, shaped by research, technology, service user engagement and professional innovation. Take, for example, diabetes care. Twenty years ago, a diagnosis of diabetes would typically mean an individual would be referred to hospital-based specialist and treated on a long-term outpatient basis. Over time, more GPs have become confident to initiate insulin and more diabetes specialists have become community-based. In the past decade, there has been increasing recognition of the necessity of a bundle of services such as foot checks and retinopathy. Multidisciplinary teams have developed to coordinate services. The new frontiers of quality of care, however, recognise that the needs of people who have diabetes are broader, as are their own capabilities to meet their own needs. This means understanding addressing psychological and social needs; and understanding individuals' capacity for self-care and self-management; and recognising the full breadth of human experience, not just labeling a person as a "diabetic”.
Delivering holistic, high-quality care demands a fundamentally different approach that starts by understanding what individuals can do for themselves, the support that they want and need and the multi-talented, multi-disciplinary team, that can deliver that care and support, working with the individual and their personal support network. Achieving such high aspirations requires not only that we work better together, but that we fundamentally change the model of care in which we work. The goal of the Whole Systems programme is to support the change in care so that every aspect of a person's physical, psychological and social needs are met in a holistic and meaningful way.
As an example, the exhibit below tells the story of how care could change for a single person living in North West London. It provides a hopeful vision of improved care that we can work towards together. This chapter will then present a series of steps that providers can take to innovate and implement a new model of care.
The defining feature of the Whole Systems approach is to cast off existing institutional arrangements and instead to focus on the needs and wants of each of the particular population groups described in Chapter 4: What population groups do we want to include? That is why groups were established with people in each of them who have broadly similar needs. Whilst care will need to be tailored for each individual, care models must be defined for meaningful population groups at sufficient scale to organise services. This chapter assumes that the population group – and outcome goals – have been selected already, so that it is clear who the model of care is being designed for and why.
Avenues of Innovation: The Opportunity
In imagining new models of care, there are at least five avenues of innovation that can be followed – those places which have historically been neglected and that offer new opportunities for creativity. We want to empower people to take control of their own care. We need to support people to work as equal partners in their care with their care professionals and to support them to live not only healthy lives, but also independent, fulfilling, dignified and happy lives. These avenues help us to achieve this.
1. Individual empowerment and self-care.
The individuals understand their own needs and aspirations better than anyone else, even those in a professional capacity. It is increasingly recognised that many individuals can and want to do more to care for themselves – and that the health and care system's role is to support and empower them to do so. Not only can more informed, engaged and educated individuals do more for themselves, they are likely to take better care of themselves too. The first question, therefore, in designing the features of a model of care should be ‘what can individuals do for themselves and how can they be best supported?'
2. Personal control of care.
Part of providing more integrated models of care is involving the individual in the services that form the foundation of that care. A proven way to do this is to hand over control of care, including by way of a personal budget, to individuals and their carers. This can ensure that care is delivered in the way best suited to each individual's needs, and that people are more engaged in delivery of that care.
3. Collaborating with and supporting carers.
Carers are often rightly described as the unpaid workforce within the health and care system and should be recognised as an invaluable source of support to many with long-term care needs. By focusing on collaboration with carers, understanding the unique role that they play in care and the rights that are attendant to that role, providers could help ensure that they are supporting all possible avenues to good quality care. To maintain their own physical and mental-health and well-being, carers should be provided information, support, respect and recognition from the professionals with whom they are in contact. Improved support for the carer can also lead to better outcomes for the person being cared for.
4. Community capital.
The communities that surround individuals and their carers are vital to the physical, mental and social support that they receive. Examples at the most local neighbourhood level show that close-knit and vibrant communities are fundamental, to compassionate and supportive care. By investing in programmes that strengthen social capital, help to develop community identity and a sense of inclusion across North West London, providers could tap into a vast resource that has long been neglected – and often with improved outcomes and value for money.
5. Embracing proven technology for health.
Proven technologies – from mobile phones to social media – can enable and enhance new models of care. These can range from connecting people to community resources and other individuals, enabling people to access services and information about their care more conveniently to increasing the effectiveness of providers. Many of the most effective innovations repurpose existing technologies – such as creating a service user Facebook group or using mobile or e-mail to access professionals – rather than creating new devices or bespoke systems.
Designing the most effective and resilient new models of care will mean collaboratively exploring these avenues of innovation, building a fundamentally different – higher quality and lower cost – way to care and to support people to lead healthy, independent and fulfilling lives as active members of their communities. At their heart is a simple idea: to make the fullest use of all the talents of people, professionals and the communities in which they work and live.
Foundations: The Essentials
Innovation takes place from a platform of good practice: the systematic application of what we know works and should be universal. From a review of the evidence from North West London, allied with a wide-ranging review of published literature, the Population and Outcomes working group has identified four essential features that characterise good practice. They are the following:
1. Self empowerment and education
2. Multi-disciplinary teams
3. Care coordination
4. Individualised care plans
These good practices can be found in many parts of North West London already. The challenge is to incorporate them into the models of care for the future to ensure that they are delivered universally. In assembling these interventions to form new models of care, providers should consider how to build in all five avenues of innovation described previously.
Establishing the case for designing new care models, the potential avenues of innovation and the existing evidence for good practice provide a strong foundation for beginning to imagine new models of care. We now turn to how local people who use services, commissioners and providers can work together to become the architects of new models of care.
This section is meant not only to provide a road map for providers across the system to create new models of care, but also to present a rich set of innovative ideas that providers can use to push beyond what has been proven to work. This means embracing new possibilities that go beyond the published evidence. As was pointed out in the working group, "there's no double blinded, randomised control trial to say jumping out of an aircraft without a parachute won't kill you, but we all know it's a bad idea”. We need to go beyond evidence alone to unlock the full creativity of people and professionals.
What are the steps to designing a new model of care?
The rest of this chapter will outline a set of steps that providers will need to go through to design a new model of care. The sections that form the remainder of this chapter are organised around these steps.
The process to designing a new and innovative model is an iterative one. Providers will need to innovate and tweak their models based on the resources that are available. This means that the design process, the workforce planning process and the financial modelling process need to be combined into a single set of steps. Throughout all of the planning, the individual must remain at the centre. Our case for change centres on a new system organised around the needs of individuals not constrained by organisational or budgetary boundaries. This process should support new models that are focused on people, and keep the needs of individuals at the heart of everything we do.
The steps below assume that commissioners and providers have already gone through some of the preliminary work of choosing a population group and setting outcomes goals. The design of the model of care is entirely dependent on these two steps having happened already. For more information on doing these things, please see Chapter 4: What population groups do we want to include? and 5: What are the outcomes to be delivered? respectively.
1. Convene for co-design.
The first and most important step for providers to create a new model of care is to establish a co-design process. This means creating a plan to engage with service users, local health- and social-care commissioners and organisations across their patch, including the community and voluntary sector to co-design the model.
2. Understand current care and future needs.
Understand the baseline of where resources are used today, spend of the population, and the variation in activity across the population group, as well as future needs.
3. Set vision and goals to achieve desired outcomes.
Set both care and financial goals that will meet the outcomes measures that have been agreed with commissioners.
4. Design the new model of care.
Design the services, features and specific interventions that will comprise the new model of care.
5. Define who will do what, where and when.
Providers will need to establish who will provide interventions, what specific services will be offered to whom, where they will be provided and how often.
6. Calculate the cost of the care model.
Providers and partners will need to work together to establish the costs of the whole model, and then plan how baseline workforce and finances will be shifted to the new model.
7. Establish overall impact.
Providers will need to establish the impact on outcomes and finances that shifting to the new model will create. This step should lead back to step 4 in an iterative design process, as visualised in the exhibit below.
The following seven sections of this chapter will detail these steps and present the steps to design disruptive innovation in care models in North West London.