The International Integrated Care Models podcast

This podcast was recorded and produced in 2020, pre-dating the COVID-19 pandemic.

Thanks for taking the time to listen to this NHS Confederation podcast. To find out about all the latest news and events across the Confederation, visit www.nhsconfed.org.

James Maddocks

Hello, my name is James Maddocks, and I am the international policy and programme officer at the NHS Confederation. Welcome to the first in a series of podcasts that explore how NHS organisations can learn from, and in some cases, have already adapted, existing international integrated models of care that seek to break down the barriers separating the services provided across the health and care system.  

In this series we will hear from experts from across the globe about how their models of integrated care are creating more effective and positive pathways for their populations and increasing the efficacy and outcomes of the services provided by their organisations.  

In this episode, we will explore the ESTHER approach, originally developed and implemented in Sweden, and now adapted by the Kent and Medway Design and Learning Centre for Clinical and Social Innovation. The ESTHER approach is designed to personalise care for the patient in such a way that their pathways are seamlessly coordinated across complex organisational, service and professional boundaries.

Anna Carlbom

It's about the person. It's about building the system and the support around the individual rather than trying to squeeze the individual into existing processes and programmes.

James Maddocks

We'll hear from a real-life ESTHER, who will talk about their experiences of the ESTHER philosophy in action.

Marion Keates

It's not just about, okay, so this is how we treat stroke patients… we have to do this, this and this. No. It’s how you treat a whole person and the whole family.

James Maddocks

And we'll hear more about the benefits of holding an ESTHER Café.

Ann Taylor

The ESTHER Cafés are amazing, and they’re essential for everyone to understand that every solution may be different, and every person is different.

James Maddocks

We sent our reporter, Joe O’Hagan, to one of these ESTHER Cafés to explore more about how this integrated care approach is being deployed in Kent.

Joe O’Hagan

As I arrived at this community centre in Aylesford, I was struck by how everybody was wearing ESTHER badges that were pinned onto their purple ESTHER branded shirts. This was clearly more than just a brand. This was a culture, a culture that they proudly embraced and constantly wanted to promote and share. So, this concept obviously means a lot to the people involved, but how did it come about?

Dr Robert Stuart is a clinical designer at Kent's Design and Learning Centre for Clinical and Social Innovation.

Dr Robert Stuart

This is about us looking at what are the new solutions that we can find to meet the current challenges facing the 1.8 million people in Kent and Medway. And we are designing, co-designing and also now using co-production to co-design better, safer, cheaper and different care to make out-of-hospital care safer for both citizens and the professionals.

We are looking at how we break down the barriers between organisations, between professions, even between people's personal agendas so that we can really understand how to meet the needs, and also to meet what matters to the person.

Joe O’Hagan

And to really break down those barriers between patient and clinician, Kent’s Design and Learning Centre needed to come up with a solution that could be embedded throughout different clinical settings, sustaining that clear message of putting the patient first. And this is where ESTHER came in. The centre, alongside the NHS Confederation, made a site visit to Jönköping in 2015 to see the ESTHER approach in action after research showed there was a significant reduction of emissions in Sweden, partly through this approach.

Whilst in Jönköping, the team met Anna Carlbom, one of two coordinators in the region who later was given the opportunity to come over and support the implementation in Kent.

Anna Carlbom

The background of the ESTHER model is that it was first implemented and built up in Sweden in 1997 as an action to try and tackle the issue that a lot of, at that point, mainly elderly, frail people were stuck in hospital for quite a long time when it was quite apparent that they could have better and safer care in their usual environment.

The steering group wanted a name, a person's name rather than calling it something like ‘better life for the most frail citizen’, just to make it human and to give everyone the chance to actually picture a person when we were talking about it. In the meantime, while the planning was going on, the group heard about an old lady in her late eighties who had to go into hospital due to heart problems and it took her over ten hours before she was in a bed and during that time she had to repeat her story 32 times, and this lady was called Esther.

We try to have the approach that instead of having assumptions and just looking at what's wrong with people, what's the matter with them, that we start all conversations with them by asking them what matters to you - to make sure that what we're aiming for is not just only to get them well and better supported from a professional perspective, but also make sure that their goals and needs are met from what they experience themselves.

Joe O’Hagan

To really make sure that this objective of meeting the goals and needs of the patients in Kent, the team run regular ESTHER cafés.

Bex (real-life ESTHER)

When it's time for me to go home, I've offered to pay the cab fare, but they said no, wait for the ambulance people to drop me off home and it took me six hours in the discharge lounge.

Joe O’Hagan

That was Bex, a real-life ESTHER, sharing her story at today's cafés.

Anna Carlbom

An ESTHER Café is an opportunity for a real-life ESTHER to share their experience of care and support, both what went well and what could have been done better. And this opportunity is then shared with professionals from various organisations and stakeholders so they can listen to this story and look at how can we change and improve our services so that the next Esther has a better experience, but also listen to the good experiences from ESTHER, how can we do more about that and make sure that more ESTHERS benefit from what's already good in the system.

Joe O’Hagan

Karen Jarvis-Keesaw is a workforce project officer in the Design and Learning Centre.

Karen Jarvis-Keesaw

It's really good for the people that come to the cafés to share bad experiences as well as good and to get it off their chest. It actually makes a real difference to them. And knowing that somebody is listening with a view to actually trying to take it away and make a difference rather than just a normal conversation is quite important, I think.

Anna Carlbom

I think the most challenging feedback from the cafés would be when professionals immediately feel that ESTHER’s experience is related to either lack of resources of any kind or legislations. Well, I'm sorry you felt like that, but legislations tells us this and that. But our approach to try and challenge that challenge is, yes, we do have the legislations, we do have the lack of funding, but try and look at it with fresh eyes. And no, we can't change the legislation, we can't draw money, but there is always a tweak we can do. So, the challenge may be then to change people's mindset, to get away from how it actually is to how it could be and that it is possible to change despite all the restraints we have.

Dr Robert Stuart

One of the big challenges is that everybody thinks that they do personalised care. But actually, did we? And couldn't we do it much better? What we're trying to do here is to sort of create a common approach, a common communication, a common language so that people actually are understanding that we're trying to do this across organisations. And in fact, if every organisation has their own way of delivering personalised care, then of course that's very confusing for the person and quite often the person doesn't then become part of the bigger team.

Joe O’Hagan

Very much like an ESTHER Café held in Sweden, I have been greeted today by clinicians, ESTHER coaches and ESTHERS themselves. However, I've also met ESTHER ambassadors, something you wouldn't find in Sweden. This is because the NHS is a much bigger and more complex healthcare system than Sweden, where the ESTHER approach was simply rolled out system wide. Kent and Medway realised that they needed to add something to the existing model to get the message of ESTHER out to the wider sector.

Anna Carlbom

So, we came up with the idea of reaching more people with the basic knowledge by creating something we called ESTHER ambassadors, where you get either an e-learning or a one-to-two hour face-to-face training, where we talk about the core bits of ESTHER, the core values, the ESTHER Cafés, the coach training, and that is also made mandatory for care agencies with a contract with KCC. You have to have a certain amount of your staff ambassador trained to in order to keep your contract.

Joe O’Hagan

And today there have been 2,170 people who have signed up to be ambassadors in Kent and Medway.

One of those ambassadors is Ann Taylor, who is the chief executive officer and founder of Hilton Nursing Partners.

Ann Taylor

So as an ambassador for ESTHER, this is really prevalent to the whole ethos of Hilton Nursing Partners because Hilton Nursing Partners was born out of an experience. A personal experience with my own mum who wasn't being listened to. Several admissions into hospital, directing into care home placement, misdiagnosed with dementia when in fact she had a really severe infection, and neither her or her family were being listened to.

Therefore, I decided that I would break the system to ensure that both my mum and every other ESTHER that comes after my mum were listened to, were understood and that the pathway was easy to manoeuvre and they actually ended up where they needed to end up.

Joe O’Hagan

An ESTHER ambassador can enhance their skills and knowledge about the philosophy by becoming a coach.

Anna Carlbom

The ESTHER Quality Improvement Coach Training, which runs over four days, one day a month, where we go more in depth in asking are we really as person centred as we think we are? And how can we become even more person centred? How can the system allow us to be more person centred? But also quality improvement… what is quality improvement? And what tools do we need to make quality improvement?

And the difference with an ESTHER improvement coach and other improvement coaches is that all ESTHER coach improvements need to benefit the real ESTHERS as well as the organisations. It also contains training in coaching. Just because I've taken the coach training, I'm not going to do all the hard work at my workplace. I need to invite my whole team to participate in this and make them feel ownership in the improvement work. That's again key to make it a success.

Joe O’Hagan

An ESTHER coach isn't a role in itself but something you embed and run alongside your current role. This has meant that Karen, who we heard from earlier, has been able to use her skills as an ESTHER coach in previous frontline roles in quality improvement and as an assessment officer.

Karen Jarvis-Keesaw

It's a mindset. ESTHER is a real mindset. It's about a way of thinking. And it's a reminder to me as well always to think holistically, always to think wider than the actual reason that I'm doing what I'm doing for the job I'm doing. And I'm very proud to be an ESTHER coach.

Joe O’Hagan

At the end of the ESTHER coach training, individuals are asked to take on a project to showcase them either sharing their learning of the ESTHER approach or using it in action themselves. Karen's project was to get into all the home care providers in the area and to train them in ESTHER.

Karen Jarvis-Keesaw

I went into one meeting once and the cook from the care home was attending the team meeting and happened to say something about: “Oh Bill was talking to me the other day and said he'd like to play the piano”, because they had a piano in the room where the meeting was, and so I said: “Is the piano tuned?” And they said: “No”. But then all the others said: “Well, I didn’t know Bill played the piano.” And this is like the manager who had just in passing, mentioned something to the cook. As a result of that, they then got the piano tuned and Bill is now able to play the piano. And it was just a small, tiny thing like that, but really meaningful and important.

And because they saw that, they then thought, this is so amazing that just a little conversation with somebody could just tell you that actually you just have to listen to what people say to you and then try and come up with a solution for something.

Joe O’Hagan

This collaborative learning and understanding between different clinical settings about an ESTHER is not only shared through the philosophy or through the coaches themselves, but also when they come together at the ESTHER Cafés.

Ann Taylor

So, it is really important that we understand each other's perspectives and each other's roles within a very large system. Each one of us is a very small cog in a very big mechanism. And if you don't understand the reasons that other parts of the system are working or how they need to change or why they do what they do, you will not get the whole picture and you will not get the journey from ESTHER from start to finish. You will not understand it and you will not understand your part in that.

So, sitting here today and actually listening to other people's roles within ESTHER’s journey and how they perceive things and how they deal with things actually gives me insight into maybe we need to look at how they do things and fit our system around the whole system so that ESTHER does have that seamless journey.

Joe O’Hagan

And what about the ESTHERs themselves? What's in it for them?

Dr Robert Stuart

One of the things that we've heard is that they are really amazed that people want to hear their story and not only want to hear their story but make them as part of the ways that it could be done better in the future. So, this is really about a type of co-production that we value what the person has to say, and we know that the impacts of this will make their experience and, more importantly, the experience of future people better.

Joe O’Hagan

And I got in touch with Marion Keates, one of the ESTHERs who unfortunately couldn't attend the café. Marion was very keen to share a personal story of how the ESTHER philosophy has had a positive impact on herself and her late husband, David. David suffered a major stroke which left him severely paralysed in 2015 and was taken to a non-ESTHER care home in early 2017 after his condition worsened.

Marion feels that they were both let down by the system and a lack of doing what was right for David at the time.

Marion Keates

I really was a wreck. I’d look at the phone and think I can't bear to ring them up and ask them to explain this or that. And you give your loved one to these people, you are completely on your own. Everything you have to do, you have to do yourself. No one's there looking after you and no one is really saying I could do that for you.

For example, to get him a wheelchair. I had to fight and fight and fight and it was only when someone said, we’re going to appeal this to the CCG that he eventually got it. I think they just gave up on him really, the whole system. I think if he'd had some more care at the beginning, he might have been a bit better.

Joe O’Hagan

Marion’s stress levels increased even more after the care home, without consulting her, decided that David was no longer allowed to stay there because they didn't feel that they could look after him. This is where Marion found Hawkins House, a care home which embedded the ESTHER philosophy.

Marion Keates

The receptionist looked up with a lovely smile on her face and said, could she help. And I am sort of saying, I've come to see if you’ll have my husband to live here. I was crying and she got the deputy manager, and they took me in a room and talked about it. They were lovely. And two days later I went back and met the manager and the caseworker from social services, and they all agreed that David could go there.

And the manager said, I don't see anything in what you said to the caseworker, I don't see anything that we can't look after him because that’s what we do. I didn't know anything about ESTHER when I went to walked into Hawkins House that day or even the first few days. But I knew that they seemed to care about me as well as him. But because of how the people treated me, I thought okay I'm going to go for this place.

Joe O’Hagan

And it's not just the carers or health professionals, but all the staff from cooks to cleaners that have to buy into the ESTHER philosophy in the setting. And Marion saw this in action when the housekeeper of the care home stopped her in the middle of the corridor after engaging in a meaningful conversation with David.

Marion Keates

She goes into David's room every morning, says good morning, and he might answer, good morning. But this particular day he had said to her, the birds have all gone. So, she realised that she had a chance to get his interest. And she spoke to him and it turned out that he liked watching the birds and she said to me, I wonder if you would allow us to put a bird feeder outside the window and would I mind?

And I said, oh I'd be delighted. That was treating him like a human being, not just a person lying in a bed. That was really good. He wasn’t really able to appreciate it that much but I did. I did because she cared.

Joe O’Hagan

Marion telling a story of both what good and bad had looked like to her is important to ensure that the clinicians have a good understanding of what matters to ESTHER. But it is also important that these stories are constantly relevant to the ever-changing patient with different needs.

Dr Robert Stuart

It's important that we listen to these stories on a regular basis, because part of the philosophy is that this should be continuous quality improvement, i.e. what is happening today that allows us to then ensure that the ESTHER approach is really vibrant and also improves not only the person's experience, but actually also the professional’s experience. Because time and again, we hear that it's not because people don't want to create person centred care, it's that often the system gets in the way.

Joe O’Hagan

The ESTHER approach has attracted interest far and wide, with the team in Kent now involved with Empower Care, an initiative to take their learning to other parts of the European Union. Robert is also keen to expand this throughout the whole of Kent and other regions in the UK and offers up some advice to how they should implement this.

Dr Robert Stuart

We know that it's quite easy to set up another pilot. We have taken four years to get to where we are and we are really on a big improvement at the moment and really making this have a big impact.

So, we would encourage that other places that might want to implement this don't just try and do another pilot, but see how through co-implementation and co-production, potentially in partnership with our Design and Learning Centre, to be able to implement the ESTHER approach in that organisation or across their system.

Ann Taylor

I've learnt from this process, never assume, never consider that your situation is the same as anyone else's situation.

Karen Jarvis-Keesaw

Listening to people is absolutely crucial because that's the way you really get to find out about the person themselves.

Anna Carlbom

By having the ESTHER culture as a core in your organisation, that empowers the staff out there to take actions and to make all our ESTHER’s lives better. And I think that is a very good selling point if you want to employ staff for the future that you can actually make a difference for the people that you're serving.

James Maddocks

The ESTHER approach is showing how putting the patient experience firmly at the centre of service and their design and constantly seeking to improve care is returning positive outcomes for patients, their carers and organisations alike.

We hope that you enjoyed this podcast. If you would like to learn more about the ESTHER model you can find a link to a full report by visiting our website.

In the next episode we'll explore the Healthy Homes and Neighbourhoods model developed in Sydney, Australia and find out how they connected services for at-risk families in order to break the intergenerational cycles of deprivation and ill health.

Preview clip for next episode

We are working on child and family service, but in reality it was a child service. We often weren't really addressing the needs of the adult members of the family and the child is very dependent on the health and wellbeing of the adult members of the family.

James Maddocks

Thanks for listening

This podcast was recorded and produced in 2020, pre-dating the COVID-19 pandemic.

Thanks for taking the time to listen to this NHS Confederation podcast. To find out about all the latest news and events across the Confederation, visit www.nhsconfed.org.

James Maddocks

Hello, my name is James Maddocks, and I am the international policy and programme officer at the NHS Confederation. Welcome to the second in a series of podcasts, looking at how NHS organisations can learn from, and in some cases have already adapted, integrated models of health and care from abroad.

In this episode, we take a look at the Healthy Homes and Neighbourhoods model, an integrated care initiative for vulnerable families living in the Central and West parts of Sydney, Australia.  

The model came about because it was identified that despite previous government interventions, in some Sydney communities there remained a high concentration of families living with significant social disadvantage, barriers accessing health and social care services, and with multi-morbidity problems developing in inter-generational cycles.  

The Sydney Local Health District developed the initiative in partnership with the community and relevant agencies to better connect services in order to address these barriers of access, and to ensure families have their complex health and social care needs met. 

 Professor John Eastwood is the director of community paediatrics for the Sydney Local Health District and director for the programme. 

Prof John Eastwood

This initial work was done back in 2013 through to 2014 in partnership with our community services, state run services, housing, the local federally funded Primary Health Care Network and the Department of Education. The project is led by us and the health service, and the idea is to achieve the vision of an integrated service system that supports the families and acknowledges how the social determinants of health are impacting on them.

A lot of what we've been trying to do is actually improve collaboration between government agencies and government-funded agencies. It's been part of a bit of a system reform process.

James Maddocks

Before the model was implemented, many of the services working with the families were operating in silos, and this led to poor engagement and communication. In these instances, the child's medical needs may have been met, but their wider social needs and those of the whole family weren’t.

Prof John Eastwood

Some of our families are quite traumatised by historical disadvantage marginalisation. And our First Nations people in particular, have suffered a lot of historical trauma in Australia. And services would often blame the families for poor engagement. We actually realised early on that it was actually poor engagement of the services with the families. The interventions that were being provided were of short duration because of the contractual arrangements. As a paediatrician, I know my paediatricians would often complain that they had referred a family to a service only to find when they reviewed them that the family that had received the six-month intervention was no longer allowed to have any further intervention.

We are a working child and family service but in reality it was a child service. We often weren't really addressing the needs of the adult members of the family and the child is very dependent upon the health and wellbeing of the adult members of the family. A lot of our understanding of primary healthcare and health promotion was rolled into the model and the very strong working partnership that we had with our child protection agency was absolutely critical to the final design.

We took a bit of a leap of faith. We did actually ask the people putting the tender out if it would be alright if we submitted a tender that embraced the social care sector, that addressed population health issues and collaborated beyond the health sector, therefore with our government departments.

James Maddocks

There is a need for strong engagement and continuous work from all parties when implementing a model of this kind in scale. However, this can bring significant challenges. Erin Miller is the programme manager for Healthy Homes and Neighbourhoods.

Erin Miller

Everyone was so keen at first, but when we started to implement things it required people and organisations and teams to shift what they were doing. Or we questioned things and we challenged things slightly or we asked them to contribute. That's when problems started to arise.

I guess another challenge was really about how we communicated about the initiative. A lot of our partners saw us as a really concrete clinical service, yet another service that's going to provide something to patients in the community. Whereas we saw ourselves as a bit of a change agent and we had some projects at that more systemic level as well, which some of our partners had trouble understanding and seeing that connection.

James Maddocks

It is easy to fall at the first hurdle when implementing a complex organisational work change. However, the success of the model has been down to persistence in overcoming these challenges.

Erin Miller

When we were wanting to maintain that stakeholder engagement, always collecting patient stories was really important. What better way to convey what we're trying to do and why we need to work this way than telling a story of a family? So, we always made sure we remembered really good patient stories and family stories that reflected what we're trying to do.

And we made sure we told those stories at all sorts of meetings, at governance group, board meetings, the chief executive at steering committee meetings, because it really just nicely highlighted what we're trying to do and why we're trying to do it. As well, I think that the way the initiative was designed, we've got some really high-level systemic projects, plus care coordination to individual families. So working with a partner agency where you're trying to shift something at a more of an organisational level is often complemented by some of the casework that our clinicians are doing with those families.

I think if we didn't have the casework, the organisational-level projects would have been more difficult. Place-based work was really important as well. So, we had our staff from our health service sitting within hubs in the community with staff from different agencies and that just allowed a lot of knowledge transfer between those agencies that helped staff to understand their mutual roles.

It increased trust between those professionals from different agencies and it really helped with referral pathways, triaging, multi-agency casework. And then the knock-on effect was when we wanted to do a project around something it really helped with that.

James Maddocks

This collaborative approach has brought benefits to clinicians and service users alike.

Prof John Eastwood

We've found that the clients who were previously disconnected from services definitely became a lot more engaged with services. Clients who felt disempowered and overwhelmed by feelings of hopelessness are now feeling more empowered and setting long-term goals. Many of our clients didn't have a consistent general practitioner, and we've now been able to document that they have a general practice home.

Referrals and consultations with other services are occurring far more rapidly than they did previously. The services that we're working with are having a better understanding of health. Joint assessments are now a lot more common than they used to be. Finally, we've done some analysis of what's been happening with our hospital admissions, and we've been able to identify that the Healthy Homes and Neighbourhoods initiative is reducing emergency department visits.

James Maddocks

Communication has been important in ensuring the model works effectively for those who access services in the region.

Erin Miller

When we're communicating with other providers about our patients, we've learnt pretty quickly that we need to thoroughly understand legislation and privacy codes related to information sharing. Not only because we want to make sure we comply with that, but we've noticed that sometimes a lack of understanding of that legislation and those codes makes people a little bit more risk averse and not willing to talk about some things which legally they can talk about and legally they can share that information, particularly when it comes down to the safety and wellbeing of a child.

We also know that sharing information and discussing things with a colleague is more time-consuming and it's sometimes easy to say that we're not allowed to do that. So, making sure that our staff know the legislation and know what they're able to ask for and I guess promoting that and making sure our partners are aware of that has been really important.

We've also brought some of our partners who don't work for health onto our health system as a contingent worker, so that they're able to view health information and therefore better meet the needs of some of the families. Sometimes families assume that everybody talks about things and get frustrated when they have to retell their story. Or sometimes that can be, it can retraumatise families when they have to retell this story to different agencies.

So this workaround of having a contingent health worker on board has been really important.

James Maddocks

The amount of expertise brought together by the team enabled the planning and implementation to be catered to specific needs and to a wide range of potential issues.

Prof John Eastwood

The design brought together the international understandings about primary healthcare, founded on the principles of the AMA declaration and our more recent understandings about population health management and how accountable care organisations might approach these issues. The design also drew on some of our understanding from the integrated care sector about, and accountable care organisations, about the importance of risk stratification.

So, the first component of the project is actually around identification and offering packages of care according to that need. There was a lot of theory drawn from our health protection understandings and from our understandings of the delivery of child and family services. For example, we drew on the teachings of Hilton Davis around family partnerships. We brought together what was going on in New South Wales at the time in relation to collaboration between government agencies and some of the work that was being done at a state premier’s level.

We had the context of the federal system and the difficulties that we were having between state and federal government. And at the time that we designed this initiative, we drew on some of the work from the United States around family healthcare homes, hence the importance of the general practitioner as a family home. The child, parents and grandparents all need to be in scope.

And as we found many a time, the grandparent was the backbone of the family unit, or an auntie or uncle. And it was that working in that multi-generational and intergenerational way that was important to the way that we focused on the parents’ needs and how we could then extend that understanding across the whole system, because the health and social care system doesn't necessarily understand things that way.

They will be working with dad’s sore back or mum's mental illness or the child's behavioural problems without actually seeing the holistic connection between all of those.

James Maddocks

Some of the learning from the early stages of planning could be useful for NHS organisations who want to take on a similar model.

Prof John Eastwood

We had been working over several decades in partnership with our other stakeholders. And even though governments changed, policies changed, that stakeholder engagement in the development of the strategy from the very beginning was very important. Clinicians tend to work at a clinical level. Managers work at a management level. When the planning for the project started, there was a real risk that it was actually just being planned at a management level. And it would not have been successful if we hadn't worked at multiple levels at the same time.

So, we were working at that grassroots clinical level in the hubs. We're working at that inter-agency level within the local government areas, and we're working on senior management across government departments at a senior level, and doing that simultaneously.

James Maddocks

The initiative has already seen some positive outcomes since its implementation in 2013. But what next for the model?

Professor John Eastwood

In one of the large public housing estates, the housing managers asked us if we would extend the model for those with palliative care, those with aged care, and those with adult chronic mental illness. So there is work going on in the district to see if we could have Healthy Homes in Neighbourhoods Plus-type model, whereby the model is extended to those other population groups. That's to adults who don't have dependent children.

Erin Miller

Some of the districts that have selected it as an integrated care initiative that they'd like to implement, look quite different to our districts. They're rural and remote communities, so I'm really excited to see how they implement it, how they evaluate it, and what their outcomes looked like compared to ours.

James Maddocks

Thank you to John and Erin for taking the time to speak to us through a specialist lens. Their detailed analysis has demonstrated the practical problems faced by health systems when trying to integrate services, as well as the solutions used to overcome them.

Communication and mutual understanding of functions and the multi-professional and stakeholder development approach among others, are all areas of shared challenge as we integrate services in the NHS. And therefore, despite the differences in our two systems, the insights shared by the Healthy Homes and Neighbourhoods model offers potential solutions.

If you would like to learn more about the Healthy Homes and Neighbourhoods model, you can read our full report by visiting our website.

In the next episode, we take a visit to the Imperial College Health Care NHS Trust to look at the Connecting Care for Children programme, which, like the Healthy Homes and Neighbourhood Model, has been developed with a focus on better connecting services for children. In this case, between primary and secondary care.

Preview clip for next episode

So the model came about because there seemed to be an obvious gap in the system. When the GP was able to look after children really well and knew me well enough to contact me if he or she was worried. Actually that child got really good care.

James Maddocks

Thanks for listening.

This podcast was recorded and produced in 2020, pre-dating the COVID-19 pandemic.

Thanks for taking the time to listen to this NHS Confederation podcast. To find out about all the latest news and events across the Confederation, visit www.nhsconfed.org.

James Maddocks

Hello, my name is James Maddocks and I am the international policy and programme officer at the NHS Confederation. Welcome to the third in a series of podcasts that explore how NHS organisations can learn from, and in some cases, have already adapted, existing international models of integrated care.   

In this series, we will hear from experts from across the globe about how their models of integrated care are creating more effective and positive pathways for their populations and increasing the efficacy and outcomes of the services provided by their organisations. 

In this podcast, we follow on from our previous episode focusing on The Healthy Homes and Neighbourhoods integrated care initiative and take a look at how a similar model has been developed in North West London at the Imperial College Healthcare NHS Trust. 

Connecting Care for Children, or CC4C, was developed by Dr Mando Watson, a consultant paediatrician at Imperial. Dr Watson drove the initiative forward in 2014 with the aim of reducing A&E attendances and improving patient experience by connecting and improving the way children’s care is coordinated, delivered and commissioned across primary and secondary services.  

Rhodell Sherman

Seeing Dr. Watson and the GP together is like getting two for one at the same time because I'm not going to go say “oh this is what that the GP said…”, they were saying it for themselves so we don't get any mixed messages.

Diabetes

For all of us to have come together and then be able to put in a different perspective of how to care for a certain patient, which was really powerful I think.

Dr Mando Watson

Parents can get access to their trusted family doctor and their trusted family doctor can get access to a specialist at the hospital. That's a very strong message for families. So actually they stop worrying so much about their children and their child’s health and feel that the system is there for them as and when they need it.

James Maddocks

We sent our reporter, Joe O’Hagan, out to see how this model has been working and the impact it's been having on the lives of families in the area.

Joe O’Hagan

In 2015, Rhodell Sherman's life was about to be turned upside down. Her child, Micah, was prematurely born at 27 weeks and after being discharged by the hospital, developed severe breathing problems. Micah’s condition had been misdiagnosed several times by different hospitals and general practitioners, and Rhodell felt she was going around in circles whilst her son's condition continued to deteriorate. Determined to get to the bottom of the issue, Rhodell took Micah to St Mary’s Hospital where Dr Mando Watson’s expertise became invaluable. 

Rhodell Sherman

They listened to what I had to say. They listen to my fears and they're like, no, we still have to run some checks. And they did everything. And they came back and said he had HMV virus, and they kept us over there. And I think a week in the hospital, then his lungs collapsed. He was put in an induced coma. He was taken to the PICU and we’re there for a long time. And that's how I met Dr. Watson because she came in to see him after he came out of the PICU. And just by looking at him, she could tell so many things. She could tell that this child was having aspiration. She could also tell by the way he was breathing that he’s definitely asthmatic. And from the sentence I explained, she was like that sounds like reflux, so probably the food is coming back, the food is coming back up. Like not using big medical terms, that could really make me understand what she was saying. And that was it. And since then, my son has just been getting like the best care, really, that a child could possibly have.

Joe O’Hagan

Micah suffers from a range of medical issues including chronic lung disease, reflux, asthma and autism. However, he has been able to receive top-quality specialist care from Dr. Watson’s clinic for all these conditions. 

Rhodell Sherman

Dr. Watson really just put him where he needs to be in the sense that she got the SALTs team involved in his care, she got the ENT involved, she got him to Royal Brompton because he was seeing the lung specialist. He had really challenging behaviour. I couldn't manage him. I couldn’t even step out of the house with him because he’d hit me back and she got him with a clinical psychologist and now I can take my son places, which might not sound like a big deal, but it's really such a big deal for me.

And the communication is in such a way that she's not left out of anything because she wants to know everything that's happening, because she wants to see an improvement. I think the most important thing for me as well is that I'm not left out, like told you have to do this. She tells me “This is what I think is happening and I think this is what we should do, what do you think? Or what do you want to see from your child?” And then we talk about it. Of course, I'm not a medical professional, so sometimes I’m like “I think this, this and this” and she’s like “okay I think this is what you mean. Does that make sense to you?” And then we come to a conclusion before she makes a decision.

Joe O’Hagan

This expertise cannot be found in a standard general practice and was one of the main reasons why Dr. Watson implemented the model.

Dr. Mando Watson

So, the model came about because there seemed to be an obvious gap in the system. I observed that when the GP was able to look after children really well and knew me well enough to contact me if he or she was worried, actually that child got really good care.

And where there was a disconnect between the GP and the paediatrician, there seemed to be a whole lot of children falling through the gaps and there were also a lot of duplication where children may be getting multiple appointments for the same thing.

Joe O’Hagan

And this network of collaborative individual specialists has been one of the main reasons why the model has been so successful.

Dr. Mando Watson

So, the way the model works is that instead of seeing the children that the GP wanted me to see in the hospital, in the hospital, I see them in the GP practice. That means that once a month I have a presence in the practice and that, I suppose, generates corridor conversations. We end up saying, “well, while I'm here, can I just ask you about…” and what we always do is have a team meeting at the end of the clinic, which means that the GP's in the practice, the practice nurses, the health visitors and other professionals can come together, and I as a paediatrician can be part of that team meeting and we discuss cases. And we might discuss the cases that we've seen that morning or increasingly we'll discuss other cases. So that actually I am being put to much better use rather than just seeing patients face to face. My expertise can be used for the benefit of a lot more children.

The other great outcome from us all sitting in a room together discussing cases is that we will learn about each other's services and how best to use them. And it creates a really wonderful set of relationships that can be used to go much further in terms of maximising the resource that's available.

Joe O’Hagan

Mando introduced the model on a small scale to ensure it was authentically grown by GPs who immediately bought into the concept and were enthusiastic of its outcomes.

Dr. Mando Watson

So as professionals we're used to a certain way of working and if you say to a professional, actually, ‘I want you to do things differently, I want you to take yourself out of the hospital and start doing a clinic in a GP practice,’ some people are up for the challenge, but others are wary. And there's this chicken-and-egg situation where we don't have a lot of this activity going on at the moment, so we don't have the opportunity to train young doctors in a different way of working.

So, we don't then have the workforce of the future that's going to work in this integrated way. And one of the things that we do is try and bring junior doctors along with us as much as possible so that they see things, they see the opportunities and they get quite excited about it.

Joe O’Hagan

And one of the GPs who was excited about the real impact of the CC4C model is Dr Saba Rafieizadeh of Paddington Green Health Centre. Saba has worked in GP practices before that didn’t use the CC4C model and can see the overwhelming contrast in the effectiveness of the care between them and her current workplace.

Dr Saba Rafieizadeh

In terms of how I feel it improves our care, I think it's been massively beneficial in a number of different ways. The first thing is it's an excellent example of well joined-up care between primary and secondary care.

It really helps to break down any barriers between the two models of care, between primary and secondary care. And it's not always easy to diagnose, to know everything and so the CC4C clinic really allows us to get patients seen where we are uncertain of a diagnosis without necessarily doing an absolute hospital referral, which may lengthen the wait time of which they're seen. So for me, not only booking patients into a CC4C clinic, but also knowing that I can contact a consultant paediatrician via email, via phone, that same day really is very reassuring and it means that I'm a lot more confident in the management plans that I provide to patients and their parents. And likewise for parents and patients. it reassures them that we're able to contact a specialist so quickly. I think it's a beneficial thing on both parts.

Dr. Mando Watson

The benefit of working in the GP practice is that we move from being very reactive to being much more proactive. So, when I'm in hospital I'm waiting for a sick patient to come to me so that I can get involved. When I'm working in a GP practice, I can say to the GPs, ‘who are your children and how can I help?’

So, we're getting in that earlier. We're able to improve the preventative care of a child with asthma so they never get a wheeze attack, rather than waiting for them to come to hospital with a wheeze attack to try and stop the next one.

Joe O’Hagan

And thanks to the flexibility of the service at Paddington Green Health Centre, Dr Watson was recently able to come to the rescue by fitting in an emergency appointment for Rhodell after Micah developed a recurring throat infection that not only caused infuriating pain to Micah himself, but also to the rest of the family.

Rhodell Sherman

I was getting depressed with a constant illness and I was seeing my GP for that as well. So, I was like, ‘I don't think I can keep on going like this.’ And I emailed her secretary and then the secretary said Dr Watson is out of clinic at St Mary's for this period of time, but she will see you at Paddington Green Health Centre on this day.

Imagine if he hadn't seen her. He was going to keep on having that infection reoccurring because it’s something that happened like three times or so before I emailed her secretary and she had him checked, examined again and got in touch with the ENT team that his tonsils had to be removed. And I don't think that would have happened if I hadn't seen her at Paddington Green because Micah wasn’t due to see her so we would have probably still be going through that. And as much as it's having an effect on him, it is also having an effect on me and my younger child because we're not sleeping. It's a nightmare. So that service, nothing beats that.

Dr Saba Rafieizadeh

It makes patients and parents a lot more comfortable to discuss their symptoms, to discuss their issues in an environment where they've been to time and time again. So, especially for young children, coming into a GP practice where they may have been seen plenty of times versus a big hospital which might seem quite scary for them. I think it’s a lot more comfortable coming to a GP practice, to be honest with you.

And it would mean that children maybe are more comfortable being examined, parents are more comfortable discussing all their issues that they've come in for. And I think having the GP there, it gives an additional layer of confidence for parents knowing that actually this is not just a hospital consultation, my GP's also here. They know me, they've seen me, they know about my child's health. So, I think that that's important as well.

Joe O’Hagan

Soraria Viera is a paedatric diabetes nurse at the St Mary’s Hospital Imperial Healthcare. She has very little experience of the model, and therefore has minimal contact with the GPs. However, after recently attending a CC4C hub session, where she was better able to understand the needs of one of her patients, she has seen how this could be of benefit going forward for her and her colleagues.  

Soraria Viera

What I found doing this hub meeting in the GP, was actually pretty amazing. I loved the fact that there was all of these professionals that came together to talk about families and patients, even if they didn't really know or recognise any of these patients. It was good to share experiences and share their thoughts or ideas of how to manage families or these patients better.

It was really insightful to see the sort of things that they do do in the community, in these practices and how we can benefit from them, but how they could also benefit from us.

Joe O’Hagan

The nature of the model means that different specialities have been able to understand each other better, and the learning from this has been invaluable.

Dr Saba Rafieizadeh

I feel that actually I'm a lot more confident in dealing with a lot of illnesses and children that maybe I wasn't previously. There's only so much that GP training will teach you when it comes to paediatrics and having had experience of sitting in with Mando, of debriefing, of getting her feedback on illnesses, of how to manage certain things. I do think it is a two-way street as well. With a consultant paediatrician coming into our clinic, they also see the day-to-day things that as a GP we deal with. We often see patients time and time again and we look after multiple members of the family. We get a real flavour of what the household is like, what their psychosocial factors are like, what's going on in their lives.

And I feel it's quite often difficult in a hospital setting, on a one-off appointment, for a paediatrician to grasp all of that. And so, I think it's been quite useful for them to get our input in terms of a family dynamic, if there's any anything else going on that we might feel might be contributing to the child's health. And a lot of areas of uncertainty that we have as GPs, which leads to us referring in.

Having a joint consultation with a consultant paediatrician and the GP really mirroring the advice that we give to patients, the management plan that we have. Again it all comes back to instilling confidence in the parents. I think once they realise that actually we're all singing from the same hymn sheet, they feel a lot more confident in the management plan that we have.

There's less room for error, there's less room for ambiguity, and I found from my experience that actually parents and patients are much more likely to comply with the management plan when they feel confident in it.

Soraria Viera

During the hubs, I found there was a definite lack of understanding in the roles that we provide in the hospital and the understanding that GPs have in what we do.

I'll give you some examples in terms of pump therapy or multiple injections, their understanding of who decides what, what happens and the process that happens. And I guess during that I was able to then explain to them actually this is how it's done and these are the criterias and this is what has to happen for a patient to go on either a pump or not.

Joe O’Hagan

Although the model has gained considerable success locally and in focus specialities, there is still a wider scope to be made in scaling up this to a significant level.

Dr. Mando Watson

So, this is a way of working that we have started to for children, but it lends itself really well to a whole raft of specialties. Care of the elderly is the obvious one but you could also make it work for dermatology, for rheumatology, and on it goes. The point being that we have really brilliant primary care, we have really brilliant secondary, tertiary care, and creating these opportunities for the two to join up just gives so much more value for money.

Soraria Viera

I would like to use this more for us to work together, meaning GPs and us, but also for families to see us all as one and not go to the GP for I guess one thing. Obviously, we are separate, and we are I guess a specialist service and they will deal with other complexities that they may have, but it would be good for us to be able to share information and bridge that gap that we currently have.

Joe O’Hagan

Like with any behavioural change in the NHS, there are challenges that can come with implementing a new model, but ultimately there can be a substantial reward at the end of it.

Dr Saba Rafieizadeh

I would really urge more practices to get involved in setting up a CC4C clinic. Having worked in practices that don't have it in place, I can see how much more difficult it is getting paediatric advice and getting patients seen quickly in the community.

So, I really can't praise it enough and I think actually it should be implemented in many more practices.

Dr. Mando Watson

So, my advice to other trusts that want to do this is go for it. It is undoubtedly a good thing to do, and although it might feel difficult, actually it's just the tiniest change in the system. I suppose to help make that change happen, I have a few thoughts. The first is to try and do things bottom up. I've seen people try and parachute this great idea in and that seems not to work.

It's much better to get people on the ground, on the front line, who are seeing patients, who really get the benefits. And I think it's really important to think about what is underlying this. What are the design principles behind what you're trying to do? So, working on building trust and relationships between professionals, working on the learning culture so that everybody is more capable, working on signposting and really focus on what matters to patients.

If we do things differently as professionals, but don't bring parents with us, they will just carry on doing what they've always done.

Rhodell Sherman

It's nothing short of a miracle to me. I've met other mums that are also struggling to get the type of help that I think I get from Dr Watson, so I don't take that for granted at all.

James Maddocks

In this episode, we've seen the impact that joining up primary and secondary care is having on the relationships and knowledge sharing between health care professionals and the improvements in access, treatment and management for paediatric patients that is able to be delivered in a comfortable and reassuring environment as a result of this. In turn, this is supporting the wider health and wellbeing of parents and children and enhancing their relationships with healthcare professionals.

In the next episode, we visit southern Denmark and look at how this autonomous region and its municipalities use information sharing and communication to enhance patient care and ensure their journey through the different system providers is a seamless process.

Preview clip for next episode

The model is an important model for how we collaborate. Because some of the basic principles is about how to give the right data to each other at the right time.

James Maddocks

If you'd like to listen to any other episodes in the series, or read the detailed reports on each model, then you can do so by visiting our website. Thanks for listening.

This podcast was recorded and produced in 2020, pre-dating the COVID-19 pandemic.

Thanks for taking the time to listen to this NHS Confederation podcast. To find out about all the latest news and events across the Confederation, visit www.nhsconfed.org.

James Maddocks

Hello, my name is James Maddocks and I am the International Policy and Programme Officer at the NHS Confederation.  

Welcome to the fourth in a series of podcasts looking at how NHS organisations can learn from, and in some cases have already adapted, integrated models of care from abroad.  

In this episode, we go to the region of Southern Denmark, to explore how they approach coordinated integrated care across the 22 municipalities in the region through an agreement called SAM:BO.

Speaker 1

We wanted an agreement that no matter what hospital, no matter what municipality you live in, it was the same procedures, the same co-operations, the same IT platform.

Speaker 2

The SAM:BO model is one example of the cross-sectoral collaboration that's been formalised and has become a core part in how we collaborate between the sectors.

Tove Larsson

Patients are at the hospital for very short time. The SAAM:BO can support us to do quicker and better planning.

James Maddocks

We sent our reporter Joe O’Hagan to southern Denmark to discover more about the Danish healthcare system. Why the SAM:BO approach was needed and how they're using digital innovation to share patient information between organisations and support collaboration between professionals.

Joe O’Hagan

After the 2007 Danish local government reform, there was a clear distinction of what roles local, regional and national leaders had in delivering healthcare outcomes in Denmark, as the system became streamlined and tailored to more individual needs with more responsibility resting with the newly formed five regions, and within that the 98 municipalities allowing the state to focus on national policy frameworks.

The regions, meanwhile, were to look after services such as hospitals and psychiatric services, while the municipalities provided health and social care locally. This division led to the SAM:BO agreement, which was introduced in 2009, to ensure there was an exchange of experiences, development of guidelines and promotion of continuity of care as patients transition between different levels of care, which was a particular concern for a growing elderly population who relied on multiple interventions. To find out some of the challenges this agreement initially brought about, I travelled to the small town of Velje, where I met Jane Kraglund, the CEO of the southern Denmark region.

Jane Kraglund

One of the biggest challenges was, and is, that we have 22 municipalities because each municipality want to do their own priorities and they want to do whatever they find is the right way to do things. So, it is a challenge to cooperate with 22 municipalities that are independent. So, we have to be very good at persuading the municipalities to why it was so important to have one common agreement, because for the patients and our citizens, it's very important that they expect continuity in care.

Joe O’Hagan

Next, I met Tove Larssen in Aabenraa. Tove is a quality consultant lead at the South Denmark Hospital and works closely with the municipalities to ensure collaboration between them and the hospital. Tove also leads an educational course where she teaches staff in how to understand and use the SAM:BO in their daily work life.

Tove Larsson

The model is an important model for how we collaborate because some of the basic principles is about how to give the right data to each other at the right time, and also how we need to focus on having the patient involved all the time. Also, the fact that it's systemised the way we work, how we communicate. We have specific format that describes how to put data to each other, how to communicate the data needed to the other part for the planning from admission to discharge.

So, this systematic thing is very important because we are huge organisations that need to have expectations and what we can expect from each other and I think that that helps both workflow but also patient safety and the quality of how we plan discharge and the SAM:BO agreement supports that.

Joe O’Hagan

Going from a rigid one size fits all approach to a more systematic and targeted approach has brought about many benefits to the region.

Jane Kraglund

I think the key benefit is that you have a structured way to cooperate for the benefit of the patients. You know what to do. It's not arbitrary - it's planned and you know when to do things and when you know that it is better. When you are organised about something you have to do, it makes better results.

So, I think that's a good starting point, but we will never be finished. We always have to be better.

Tove Larsson

The way it compares to the old system is that before this agreement we talked a lot over the phone and if we have to write, we did it by hand. With this model, we write primarily electronic communication and that supports the data, our in-time data, and also the way the things that we document are based on the format we use, so the format also helps getting the right data to the other part. So, it's a tool to support better data at the right time.

Joe O’Hagan

Good communication is vital to ensure a seamless patient journey through different settings, allowing a discharge date to be agreed between the patient, hospital and other health and social services.

Tove Larsson

In the hospital, we have a workforce that considers, not only, but also, the collaboration between municipality, hospital and GP’s, and there we can talk about what agreements do we have and how does it function. And also, we have some employees around the hospitals that are key persons regarding the SAM:BO agreement, the SAM:BO model. We meet with these key persons and talk to them about the SAM:BO model and other agreements that we have in the collaboration between hospital, municipality and GPs.

Outside the hospital, if we look at the collaboration between the hospital and the municipalities connected primarily to this hospital we meet to make sure that there is a connection from the hospital to the four municipalities around this hospital.

Joe O’Hagan

But does this improvement in communication and collaboration really have an impact on patient satisfaction?

Jane Kraglund

Once a year, we measure the patient’s satisfaction upon a lot of things and we also ask the patients, are you satisfied with the cooperation between the hospital and the municipalities? And most patients are satisfied. But of course, I don't know if the reason why they're satisfied is this agreement. But I do think that it is a very valuable thing in the cooperation. But they are satisfied.

Joe O’Hagan

And some of that positive feedback could be attributed to the level of involvement that the patient has in their own health pathway.

Tove Larsson

To understand the patient needs, it's important to have patient involvement. When we write to each other and give each other information, it's grounded on consent from the patient. So, in that way we secure that the patient knows what's going on but also when the patient gets admitted and is known by the municipality, you could have important information brought by the municipality from the admission report. So that’s a good thing. And it comes right away. Thereby, it's also important that these data are updated.

Joe O’Hagan

Data sharing has been key to the success of the agreement, with Denmark said to be at the forefront in the application of IT Technologies in the health and welfare sector. This is because the SAM:BO agreement has allowed health innovation centres the freedom to design the future of the health system.

And that takes me to the last place on my journey around Southern Denmark to the city of Odense. I wanted to learn about all the technological developments taking shape at the Health Innovation Centre of Southern Denmark. Christian Mercado is the head of digital innovation at the centre.

Christian Mercado

We can't just put more nurses and doctors into our hospitals because there's also a fixed number of possible staff. So, one of the ways that we can deliver health care in the future, we need to turn to technology. That's why we focus on digital innovation to help us overcome these challenges in regards to how do we deliver healthcare in the future.

And at the Health Innovation Centre of Southern Denmark, we sort of have three different focuses in regards to digital innovation. One is collaboration between the health care sectors. This is where SAM:Bo a huge part of this collaboration. We also have health technology and telehealth.

And some of the similarities between these areas is that we can't just solve this problem by looking at our hospitals exclusively. We need to bring in the general practitioners. We need to bring in the municipalities and find solutions that increase the collaboration between these three parties of the healthcare sector.

Jane Kraglund

I think innovation has helped a lot because if you don't innovate things, you don't move to another level. So of course, you have to have innovation. But it's not innovation like a new thing you can buy. It's innovation that takes place among people. You have to put people in the same room. You have to put people in a position where they can develop new ideas. How can we develop this agreement? How can we make new places where we can use this agreement? And I think maybe in two, three, four or five years, we are in another place, in another level, because right now we're using the agreement by pushing out information.

Christian Mercado

One of the key philosophies at the Health Innovation Centre of Southern Denmark is we need to have a hospital or a municipality or a general practitioner involved in all of our projects. We need to make sure that the innovation that we work with have roots within the daily life of the healthcare professionals

Joe O’Hagan

Christian is a firm believer that digitalisation will be one of the main solutions to how we can deliver health care in the future and has already seen examples of how it can be of benefit to the patient.

Christian Mercado

In the region of southern Denmark and Denmark in general, telemedicine is improving the way we deliver healthcare to patients at home by enabling us to deliver healthcare services, not dependent on a specific geographical location. Currently, we are in the process of rolling out home monitoring for COPD patients, which will enable us to both increase the quality of the care for the patients, but also enable the patient to have a higher degree of personal freedom as they will not be as dependent on being transported from their home to a hospital or to a doctor's office. It’s an example of a national project that is implemented on a regional and municipal level.

We also have projects that the regions agree upon. Currently, we are implementing home monitoring of pregnant women that experience complications during the pregnancy. The case here is to ensure that the pregnant women are not admitted to the hospital but can stay at home and be monitored, and have both the foetus and the mother monitored from home.

There are then healthcare professionals within the hospital that follow the measurements as though they were admitted to the hospital.

Joe O’Hagan

So, what next for the innovation centre as they hope to continue to be that bridge between the different local and regional health settings? Could artificial intelligence provide the answer in predicting health outcomes are making early interventions?

Christian Mercado

What we've seen in regards to the maturity of artificial intelligence and the maturity of our regions in regards to adopting artificial intelligence is that we have a pretty good idea that it can help us with some of the problems we are facing now and also some of the problems that we will be facing in the future. But we're not quite sure on how can we take this technology and implement it to the maximum benefit.

That's why we distributed these €2 million to project proposals from our hospitals so we can do some different tests in regards to in this area or this for this patient group or for this specific healthcare delivery. Artificial intelligence gives us these benefits, but in these other areas, it doesn't really bring anything new to the table.

Joe O’Hagan

The setting up and implementation of SAM:BO was a result of strong regional leadership. And the NHS can relate to this with the formation of the ICSs across the country. But what is some of the advice that the NHS could take from the infrastructure needed for this kind of project?

Jane Kraglund

I think if you want to do something like that in the NHS, of course you have to do it your way but I think you have to accept that if you want to do something that really matters in respect of the cooperation between hospitals, and municipalities, you have to make an agreement and you have to make an agreement that covers everything, that covers referrals, that covers admissions, that covers everything in the patient pathway between the hospitals and the municipalities.                       

And I think you need to have IT support because it is so big that it's not possible to do without an IT system that makes it possible to exchange data and to exchange agreements and whatever you have of cooperation issues between hospitals and municipalities.

James Maddocks

Thank you to Jane, Tove and Christian for taking the time to share their experience and insights with us. The SAM:BO approach demonstrates how joined-up communication between the independent providers of health and care services across the 22 municipalities, has enabled better decision making to be taken with regards to patient management and that this is leading to improved patient experiences.

The communication is also leading to more equitable collaboration between organisations that is resulting in more innovation being developed and adopted across the region.

This been the final episode in our international integration series. We hope that you've enjoyed them and found the content useful. If you'd like to listen to any other episodes in the series or read the detailed reports on each model, then you can do so by visiting our website.

Thanks for listening.