The potential of care coordination

Some time ago I wrote a short piece about collaboration. I suggested that too often we go straight to urging it in its highest form, when the leader of one organisation is willing to sacrifice their best interests in favour of what is best for the group. Instead, I argued, we might want to develop the collaborative habit starting with more modest, but still potentially fruitful, goals: transactional collaboration, where two or more organisations do things together that are mutually beneficial; and resource collaboration, in which one organisation offers to share something (e.g. secure data, expertise, premises), which costs that organisation little but benefits those with whom they share.

A recent digital hubs webinar and visit to a hospital reminded me of this proposition.

Care coordination system

The digital hubs webinar focused on the work of both an established model in Tameside and Glossop and another more recently created hub in Salisbury. My visit to Royal Wolverhampton focused specifically on its digital care coordination system.  

Although they are geographically diverse, at different levels of maturity and vary in their design, fundamentally these systems share the same aim: to more effectively direct and coordinate people to the most appropriate services, from their first contact. This care coordination avoids unnecessary visits to A&E and stays in hospital while ultimately saving time, addressing demand and improving flow.

To a lesser or greater extent, these examples have seven common characteristics:

• They were established to address a particular issue, mainly to reduce unnecessary hospital conveyancing, admission and inappropriate demand at A&E.
• They generate measurable results. Firstly, in terms of fewer ambulance conveyances to hospitals, fewer A&E attendances and shorter hospital stays; secondly, they make more effective use of limited resources; and thirdly, greater patient and carer satisfaction.
• They involve strong and growing trust and collaboration between parts of the health and care services, and beyond into the voluntary sector.
• They receive very positive feedback from staff who gain new skills and enjoy the opportunity to resolve issues for patients and their families.
• Technology is an important accelerator of change, but partners tend to agree that the human side comes first.
• They have evolved to meet local needs and opportunities. In particular, they tend to go with the grain of organisational capacity and clinical enthusiasm.
• Once established, they tend to grow in scope and ambition. For example, through the development of models of virtual care or through using data to reshape services or stratify population risk.

The evolution of collaboration

The last two of these points take me back to thinking about the evolution of collaboration. Rather than beginning with governance, strategy or even mission, these initiatives were prompted by a concrete and pressing problem. The starting point tends to be the need for two or more partners to help each other out. For example, the ambulance service and the acute trust or primary care and community services. This emphasises the need for local discretion. NHS England has provided important and valued support to care coordination but, as it develops a pilot scheme to take the idea further, there are worries that - as with virtual care [JM5] - it will be too prescriptive and focus too exclusively on the NHS parts of the collaboration.

Collaboration tends to start with grand commitments and objectives and then tries to apply these to real-world challenges

Collaboration tends to start with grand commitments and objectives and then tries to apply these to real-world challenges. Equally, as a number of leaders have told me, pressured organisations that have only just started trying to work together, are unrealistically exhorted to behave like long-established, high-trust partnerships. Instead of this top-down perspective, we should learn from the principle of positive deviance: find where things are working, even if small scale or against the odds, and then seek to enable these experiments to grow and start to shift wider cultures, practices and expectations.

This is the potential of care coordination. Necessity has forced practical, front line cross-collaboration. The task now is to enable these initiatives, where they are thriving, to deepen and widen and to encourage new ones to take off. This is already happening in many places, suggesting there are now two tasks.

...too often short-term priorities in the NHS – especially those driven by political imperatives – push against long-term aspirations

First, to help others learn from the best practice of the pioneers, but to do so in a way that focuses on the aims and principles that underpin success, rather than seeking to impose a rigid template. Second, to think about what barriers might need to be overcome for care coordination to become the operational heart of a deepening culture of system working, place collaboration and innovation.

A final point: too often short-term priorities in the NHS – especially those driven by political imperatives – push against long-term aspirations. This, as I mentioned in my recent Stevens lecture, is one reason we have made so little progress on the leftward or upstream shift of resources. Care coordination often begins with immediate necessity, particularly winter pressures. But in fostering collaboration, seeking to enable patients to stay at home, developing community-led alternatives, expanding the diversity and use of virtual wards and the use of secure data to model future demand, it can align with where we want the health and care system to go. 

For understandable reasons, not least money and the government’s overwhelming focus on elective waiting list, most places have little time to learn from last winter and prepare for next. But in working now on winter resilience strategies with care coordination at their heart, systems, places and trusts can prepare for the near future while building a bridge to the long term.

Matthew Taylor is chief executive of the NHS Confederation. You can follow Matthew on Twitter @ConfedMatthew