Collaboration is key
To understand the quality of care that people receive and try to make sure people are safe, we need to find out what is happening locally among different health and social care services. The speed and scale of the response required by the pandemic has highlighted the benefits of collaborating to achieve creative and innovative solutions. Responses to the pandemic have promoted partnership working to drive better experiences and outcomes for people using care services.
It is particularly important that providers in a local area collaborate in the delivery of care. From our previous work we know that a lack of collaboration between local services can be a significant barrier to people getting good care.
Provider Collaboration Reviews
- Throughout July and August we will be carrying out a rapid piece of work, engaging with partners and using our data and intelligence, to review how providers are working collaboratively in response to the coronavirus pandemic.
- These Provider Collaboration Reviews will involve understanding the journey for people aged 65 and over, with and without COVID-19, across health and social care providers, including the independent sector and council and NHS providers.
- We will report back on our findings in our next COVID-19 Insight report in September and in our State of Care report in October.
In advance of our work on our Provider Collaboration Reviews (see box), in May/June we talked to representatives from a range of local stakeholder organisations and reviewed local support plans, to gather some perspectives on the extent to which collaboration was happening at a local level.
What’s the local vision?
Of the people we spoke to and the plans we reviewed, just over half said there was an agreed vision for responding to COVID-19 that was signed up to by all providers. By contrast, about a third said there was no agreed vision. A small minority said that there was an agreed vision, but that it was only signed up to by some providers.
Where local agreements were followed, services reported collaborative working towards a unified goal, while being flexibile and sharing of resources. We were given examples of NHS trusts that had modified their existing visions or strategies to ensure they were relevant to the pandemic.
The pace of change has created challenges in reaching agreement. Where there was only partial agreement, issues included stakeholders having different priorities for managing the pandemic locally.
Lack of time and prioritisation of other objectives were among the reasons where places had no agreed vision among stakeholders. There was siloed working with each provider organising its own response.
The pandemic has brought to the fore some good examples of collaboration across sectors and shared learning among services in the way they use technology. As has been seen across the country, there has been a significant increase in the use of technology and streamlined software, such as online team and multi-team working.
Challenges in systems have been managed through cross-sector meetings and networking, and early learning shared. Some services say they will continue these relationships after the pandemic.
Webinars have been used for training and more adult social care providers now have access to, and are using, NHSmail. There are many more remote consultations (GPs and outpatient clinics), which help to provide a safe way to be seen. Doctors have been able to see more patients and spend more time with them. However, one challenge in adult social care settings is how to fully understand a person’s condition – for example in treating pressure areas remotely, the need for the consulting clinician to see how the person is positioned in their bed.
The importance of shared governance in a system
There have been barriers to collaboration, including:
- multiple requests for information from different places
- using different sources of information to inform decision-making
- a sense of command and control at a regional or national level, which can limit timely local solutions
- potential for more dialogue between primary and secondary care.
However, some pre-pandemic barriers to collaboration are being overcome. The pace of change and a determination to meet the challenge of COVID-19 has put a focus on joint-working, with a willingness to collaborate to ‘get the job done’.
The importance of streamlining and securing shared governance arrangements was highlighted to support timely decision-making. This was underpinned by a clear audit trail of why, when and by whom decisions were made, which led to a much more rapid response to issues. Allied to this was a consideration of the need, in some cases, to streamline system performance management.
The staffing challenge
Among the many challenges faced by providers in recent months, services have had to consider their staffing capacity. They have tried to make sure there were enough employees with the right skills to cope with new and increased demands resulting from the pandemic.
Strategies have included the redeployment of existing staff, for example staff moving from one area of a hospital to another, commonly to critical care. Some people were redeployed to another sector, such as hospital and community staff with appropriate clinical skills moving to care homes. There have also been news stories about staff leaving their families and moving into residential care homes to protect the residents.
As well as recruiting new staff, some services have deployed staff who have returned from retirement, or used volunteers. Local authorities used recruitment campaigns to attract new staff; one of them reported a ‘bank of… unemployed (but experienced and qualified) staff… available at short notice’.
There was significant interest from the public in volunteering and supporting their local communities, but there were also concerns about the coordination of volunteer strategies, such as how recruited volunteers might be implemented in the system.
Local responses to support staff capacity also described supporting employees’ wellbeing. Examples included:
- rota systems within COVID-19 positive wards in hospitals, so that people were not always working in high pressure environments
- signposting to employee assistance programmes
- implementing enhanced risk assessment for staff from Black and minority ethnic backgrounds, resulting in more homeworking for colleagues at increased risk from coronavirus.
Providers want to build on the momentum of collaboration that has happened during the pandemic. For some, the circumstances have led to a better understanding among services and improved relationships. They have described smarter working and greater efficiency – a reduction in financial constraints has helped.
Among the benefits, some staff have been ‘upskilled’ and have taken on extra or new roles. Patients have benefitted from an increased focus on the needs of people in the local community – for example, those who are clinically vulnerable or shielding. Some services have seen improved data sharing, and changes to patient pathways with new digital solutions.
Continuing this collaboration, providers see an opportunity to resolve pre-existing problems and work together more across different pathways and services. Some services had concerns about a return to pre-COVID-19 behaviours, preferring to consider how they might streamline approaches in future to support a shared purpose. Our Provider Collaboration Reviews will look in more detail at the way providers have worked together.
Collaboration – further examples from the front line
Using a data dashboard tool developed by a local expert GP and taken up by the CCG, Nottinghamshire Healthcare Foundation Trust worked with their local integrated care system to identify populations vulnerable to high COVID-19 risk.
This meant community and mental health services could not only identify individuals under their care, but the distribution of risk across deprivation and ethnic group categories was understood by all healthcare organisations involved. The data tool was particularly helpful in ensuring that those with severe mental illnesses were identified to receive support via Primary Care Network areas, as this group is often difficult to capture through primary care data alone.
This work has implications beyond the COVID-19 crisis as it enables a better understanding of and approach to population health as a whole, identifying high risk groups down to Lower layer Super Output Areas (LSOAs) – equating to a population size of around 1,500.
Chris Packham, Associate Medical Director for Nottinghamshire NHS Foundation Trust, said they established an innovative longstanding data sharing process and encouraged local GPs to download data to a CCG-held database. The collected data helped identify quality improvement work at individual patient level for practices. Acute, mental health and community trust data was added to the database, enabling better identification of patients with higher risks of poor outcomes during the pandemic.
"The data brings population health management to life," says Chris Packham. The data is now used by an Integrated Care System to inform Population Health Management (PHM) approaches that can guide commissioning. For example, the mental health PHM work identified seven interventions/topics that could prevent escalation of mental ill-health, exacerbated by the pandemic. The aim is to collectively use resources, skills and expertise to support the local population through integrated data sharing and PHM.
The benefits of a good relationship between a care home, a community pharmacy and local GP have contributed to the care and safety of the care home’s residents during lockdown and will become a normal way of working post-COVID.
Zoe Fry, owner of Valerie Manor Nursing and Residential Care home, says that relationships developed before the COVID pandemic have been invaluable during lockdown. This has enabled the streamlining of processes around the urgent provision of care when required, allowing prescriptions to be requested, dispensed and collected/delivered within a matter of hours under normal circumstances. The pharmacy can provide a 24/7 service for urgent medication if necessary.
The three-way relationship, built on trust and shared values, has meant that if, for example, stock levels of a particular medication are low, the Steyning Medical Practice can send a prescription to the pharmacy, Upper Beeding Pharmacy, which the pharmacy will only dispense if it is needed. This also means the care home does not have to carry large stocks of emergency medication.
As well as providing guidance on medicines management, helping the home implement new guidance as it is issued, the pharmacy carries out monthly reviews of stock levels via Skype and works with the home and GP to carry out regular video medication reviews of the home’s residents. The pharmacy is available via video calling technologies, if there is a need for less qualified staff to administer medications within the home, to help provide safety and quality assurance.
Coordination of new resident admissions to the home can be eased by pharmacy involvement with GP surgeries, with the pharmacy aiming to provide correct and up-to-date blister packed medication to coincide with patients being admitted. Valerie Manor has also worked with the GP to ensure that all residents are reviewed by the GP at least every 28 days – a greater frequency than pre-lockdown and important in terms of death notification requirements.
The Five Lane Primary Care Network has aligned local care homes to the four practices in the PCN to improve continuity, reduce social contact and build a better relationship with the care homes. While this approach is embedded in the new GP contract, the partnership took this action independently on its own initiative in response to COVID-19.
Rachel Thompson, Practice Manager at the Rockwell and Wrose Practice, said that the plans to align the homes with the partnership were put in place before the crisis hit, as they recognised the growing pace of COVID-19.
This plan received very positive feedback from care home managers. Many residents at the care homes were registered under the care of doctors at another practice, so the partnership consulted with those practices, and residents and families. The partnership asked for the care homes’ help in discussing the transition with patients and relatives to seek consent and created a letter for relatives to explain the reasons and ask for their approval.
The change also found approval with the local district nursing team, which is based in the same building as the partnership. The co-location of district nursing and GPs improves the coordination of care and helps the work of the multi-disciplinary team.
The practice supplied Sats oximeters and digital thermometers to the care homes and asked staff to undertake daily observations of the residents and report any outlying readings. Staff needed training to use this equipment which was supplied by the GPs, and they were invited to take observations if any patient became unwell and needed a GP.
Since lockdown, as well as being available for urgent calls, GPs at the partnership have dedicated time every Thursday morning to perform a ward round of the residents (either telephone, video or face-to-face as needed). This step has significantly improved patient care, professional to professional relationships, networking and medicines management.
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Related news
You can read our news story about this issue of the coronavirus report:
Promoting partnership working to drive better experiences and outcomes for people.
Previous issue
You can read the issue of the report that we published in June. This issue looked at how providers were working together and how care of different groups was being managed. It also had a section focusing on primary care.