Introduction: System integration to achieve sustainable systemic change is not a new concept and something that has been around in International practice for a number of years. Experiential, comparative exploration of system models in Alzira, Boston and Washington DC (via an AQuA fellowship) highlight significant similarities with that of the Oldham economy, at the same time as identifying the stark difference in progress to develop and deploy sustainable system models in the UK. Oldham has taken learning from International best practice and used the intelligence and information to better shape the system in Oldham, aligned to the greater Manchester Devolution mandate.
By deploying the same strategic approach as International models to the urgent care system in Oldham (via a multi agency alliance partnership) we are able to demonstrate sustained quality improvements for people and system flow via a number of innovative, transformational approaches that have sustained positive impact on a reduction in unplanned admissions in excess of the National expected average (3.5%). This achievement has received National recognition (NHS England) and also shortlist for two HSJ awards (integration and quality improvement).
Description of practice change implemented: Oldham Urgent Care Alliance’s (a partnership of 8+ multi agency organisations) aim is to improve the urgent care system across the Oldham locality. It had a number of objectives: to reduce unplanned admissions to hospital by 3.5%, deliver a number of integration projects and take a performance management approach to the use of resilience funding.
Via this approach a number of practice changes are evident,
Development of a frail elderly unit which has reduced length of stay by 70-50%
Development of a multi agency discharge to assess service, impacting upon admissions to residential and acute provision and improving quality of life
Development of a multi agency Primary Care practice before the front doors of A&E, evoking public behaviour change, redirecting people to care options that befit need, a connected out of hospital.
Aim and theory of change: The initial aim of the UCA was to reduce unplanned hospital admissions by 3.5% on the previous year by re-engineering the system to focus upon improvements in the quality of care provided via a number of schemes that offer an ‘out of hospital’ alternative to acute or residential care provision.
A system governance framework and leadership infrastructure was developed to execute the strategic change across the Oldham economy. In order to drive forward this theory at operational level an independent organisation to broker the discussion, decisions, and monitor, manage and establish and report on performance was commissioned. Quality improvement methodology in the form of PDSA cycles were deployed to a number of con-current schemes, so that rapid improvements and co-design at the same time as implementation could be executed. Impact of quality improvements and sustained system improvement can be evidenced as a result.
Targeted population and stakeholders: Targeted population – the population of Oldham with an inherent focus upon frail elderly, children and young people and those most vulnerable.
Stakeholders: Oldham Council; Pennine Acute Hospitals NHS Trust; Pennine Care NHS Foundation Trust; GotoDoc (a social enterprise providing an out of hours GP service) MIO Care, (a limited company owned by the council to provide homecare and re-ablement services), Voluntary Action Oldham; First Choice Homes; GP representation and Oldham CCG.
Timeline: 12 months
Highlights: (innovation, impact and outcomes) Sustained improvement in quality of care and life chances are evident as a result of deploying this systematic approach.
A sustained reduction of 5.8% in unplanned hospital admissions achieved, despite an annual 6% increase in A&E attendances over the same period
Total estimated system saving of £2.79m.
Triage system introduced to assess conditions prior to admission.
Almost 600 fewer paediatric admissions in 2015 compared with 2014
Alternative to transfer (minor injuries)
A physiotherapy and occupational therapy service established enabling initial assessment of patients quickly to divert the patient from admission.
Over 250 deflections from hospital achieved in 2015.
Long term conditions
Pro-active and self-management within the community.
Almost 500 hospital deflections achieved in 2015, compared with the previous year.
Early supported discharge for stroke rehabilitation
15 hospital deflections for stroke patients achieved in 2015.
End of life care
An overall reduction of the number of deaths in hospital per 1,000 population of 2%
Comments on sustainability: Analysis of performance metrics continue to demonstrate sustained system impact despite growing demand.
Review of quality impacts continue to yield positive impacts upon quality.
Comments on transferability: The model can be replicated in any system/ care setting.
Conclusions: The development of a systematic system leadership and governance approach via integrated working across a number of public, private and voluntary sector organisations has yielded a sustained impact upon quality and performance improvements within the urgent care system.
The introduction of the Programme Management Office to co-ordinate and manage multiple projects across multiple partners was critical to the success of the transformation programme and the demonstration of sustained outcomes delivered.
Discussions: This theory of change continues to be deployed within the Oldham urgent care economy and there are a number of other innovations that have been deployed as a result. This theory and concept has been driven forward by a sustained fastidious leadership approach across the system with interrogation of quality and performance data to evidence outcomes.
Lessons learned: Sustained system leadership is critical to success
Interagation of International systems has demonstrated the similarities between UK systems, which has been deployed further than theory and concept and implemented to make real and sustained system change
Relationships across organisations are key to success
Integrated working is a critical success factor
Despite perverse financial incentives front line staff working in an integrated way can make real and sustained impact upon quality
The deployment of quality improvement methodology enables and embeds rapid improvement