>>Mike Pinkerton: Good afternoon everyone.
My name is Mike Pinkerton, Chief Executive at Doncaster and Bassetlaw Hospitals and we
are The Working Together Programme.
We're an existing partnership of seven acute trusts in South Yorkshire, Mid Yorkshire and
North Derbyshire covering fifteen hospitals, serving a population of 2.3 million, 45 000
staff and over 100 000 patient and public members.
Established by a memorandum of understanding in March 2013 to work together to deliver
benefits the trusts working on their own, individually, could not achieve.
And we're focused on improving quality, safety and patient experience through reductions
in variation and inequalities in care, supporting local access to services whilst maximizing
use of skilled workforce across organizational boundaries and delivering services that are
both clinically and financially sustainable.
We invested in a central PMO office in January 2014 to the tune of approximately £1 000
000 with the approach focusing on engaging frontline and clinical staff and innovative
approaches to tackle innovative issues through a range of clinical and support services projects.
Our improvements are clinically-led and driven by user needs.
Key success factors to date have been the leadership and ownership by the seven of the
chief executives guiding the direction and delivery of the projects and clinical leadership
through the Medical Directors Reference Group.
We're also engaged many other bodies as a programme with the commissioners and NHS England
and we've stimulated and energised our local commissioners to form a parallel programme
called Commissioners Working Together, also through Health Education England and the Academic
Health Science Network.
And our patient involvement approach is to use our existing partnerships' networks through
our commissioners, through our own trusts, through the overview and scrutiny committees
and our health and wellbeing boards and develop our approach as a bespoke necessary and we
have our own, one of our first patient and public engagement events early in the year.
I now pass on to say what we have achieved thus far.
>>Richard Jenkins: Thank you.
I am Richard Jenkins.
I am the Medical Director of Barnsley Hospital FT and I chair the Working Together Partnership
Medical Directors Group.
So over the last two years we've done a number of things and we're really highly motivated
to do what we could to improve clinical services as a group of seven trusts that we couldn't
do on our own.
And we selected the areas to work on, based on the similar criteria to the Vanguard Project,
to look at sustainability and equity of access.
A lot of that pointed towards problems with out-of-hour services.
So we've done a lot of work on reorganizing out-of-hour services for ophthalmology services,
ear, nose and throat or a matter of facial surgery, interventional radiology and gastrointestinal
bleeding.
None of those services are very easy to deliver across seven trusts independently due to provisional
workforce and other factors.
We did a lot of work on radiology which we were hearing about earlier.
We've also got a work stream looking at insourcing using IT enabled solutions.
We've also done a very important piece of work on-going using the Calderdale Framework
to look at competencies of the radiology workforce so that we can redesign the workforce to take
into account what we heard earlier about the lack of supply of the medical staff that,
traditionally, the model's being based on, within our working partnership of all college
and health education, England.
We've also done a lot of work on children's services.
We've got two work programmes that are, one on children's surgery and one on acute services
for children and that's the new partnership with our commissioners.
We believe from these pieces of work we can have a replicable model of bottomed up clinical
engagement that allows these services to be redesigned by the people who are going to
be working within them.
We identified some crucial enabling HR and IT strategies through that work as well.
And one of those, for example, is the use of the ICE OpenNet system, which allows diagnostic
test results for patients in our patch to be seen in any hospital and improve care that
way.
We've had a big programme on procurement which, by the end of December, will have delivered
over a million pounds of savings.
And that's being supported by a lot of clinical engagements, so not only have we found products
that are cheaper, but also clinically acceptable to the people who will be using them.
There are a number of work streams on back office function, as you might expect, including
payroll, sterile services, occupational health and legal services.
>>Jeanette Watkins: Hello.
My name is Jeanette Watkins, I'm the Programme Director.
My ambition is now to take this partnership forward building on what we've achieved to
date.
And we're proposing to do that by putting together building the high level joint clinical
strategy that will require a new appropriate palate governments arrangement for delivery,
based on a confederated approach.
The focus will be on sustainable models of acute care for both our small hospitals and
our multi-site trusts and it will utilize a three-tiered approach to identify the best
clinical and business models.
So it will be reviewing what's to be provided at local core services at each hospital to
keep the interconnected and indispensable services stable and sustainable.
Identification of other services that are intrinsically linked, which are not fundamental
to sites, but where organizations are willing to reveal tentative ways of delivery, for
example, Lead Provider or Hub and Spokes.
And looking at also our specialist service models based in tertiary centres which will
include managed care networks, options to specialist chains and risk tier patients to
where they need to go with the most appropriate acute needs.
The Collabtive Strategy will therefore support the development over the next 12 months by
ensuring that service models are networked across the partnership where they're not sustainable
on their own.
Create more clinical formalized networks to oversee clinical and service standards, reduced
variations of care through standard operation policies and agreed clinical pathways, establishing
new job roles for hard to recruit staff, greater standardization of processes and use of technology
for cancer referrals across the trust, networking radiology and pathology reporting systems
and developing our overall digital strategy.
New operating models will also be undertaken for backup dysfunctions with joint ventures.
And we'll certainly be further developing with our commissioners and expanding our perfect
engagement and consultation approaches.
>>Des Breen: Hello, my name is Des Breen.
I'm the Medical Director for the programme.
So why is?
I think we've got a track record already over the last 18 months or two years of collaboration,
both from clinical and non-clinical services, over about 25 projects.
This is not just between the trusts, they also about with commissioners and many other
stakeholders.
We've certainly developed trust within the seven partner organizations and have certainly
got a governance structure which is established, which we now know we need to develop further.
We're working with a set of principles, which we've all agreed, to try and break down some
of the traditional barriers of seven independent acute trusts who traditionally were competing
against each other, who are now trying to collaborate.
Crucially, the chairs in the chief executive office have agreed to deliver a joint clinical
strategy over five years, which I think is unique.
And they are committed to a more federated model with a five year collaborative strategy.
So we know that we need to actually start to develop our governance structure and change
the way so that we can actually develop things further.
We need to realign our decision making process to make sure we can do things in a quicker
and more productive way.
We know that we need to develop our processes for the potential changes, which will provide
improvement and quality of care.
And we're setting up joint ventures which will involve a new leadership and accountability
arrangements with both clinical and non-clinical services.
And we certainly are already engaged with commissioners, but we know how crucial this
is because we don't want to design a product that is not fit for purpose.
And also they're our crucial link to have our well established patient and stakeholder
involvement.
>>Mike Pinkerton: Okay, so just to briefly summarise.
We feel that we're tackling the big issues that are affecting acute care in the NHS,
both as providers and as commissioners.
We got a partnership and co-creation and learning approach and track record that reflects the
Vanguard approach and ATHOS.
We're developing a clear structure and process to deliver our outcomes and we've developed
standard work for application locally and replication nationally.
We want the programme to help.
We want advice and we want guidance.
We want to help break through into key areas and accelerate our programme, our cultural
change and our learning and sharing for the benefit of the NHS and its patients, both
locally and nationally.
Thank you.
>>Jeanette Watkins: Thank you very much, questions?
Questions on Working Together?
>>Participant: Thanks.
Steve Judge from NICE.
It's a question I could probably have asked of any of the applicants today, so I guess
you're just the lucky ones.
If there was one area of support that you were really looking for from any of the signatory
organizations that are supporting this programme, what would it be?
>>Mike Pinkerton: As [Inaudible] very early on we took legal advice because we're quite
clearly flying in the face of conflicting policy.
So, on the one hand where monitors saying compete, whereas the philosophy now is collaboration
and somehow we've got to actually get through that.
And if one of the things that the seven organizations can help us with is breaking down some of
that barriers.
And the second big barrier that we've come across, which we have got mechanisms in place
to get around, obviously, is the way the funding stream has worked because there is a perverse
incentive to, for some of the funding mechanisms.
And also our programme is about redistribution of clinical services, not centralization and
local.
And by the, by the very nature of those things, we will be redistributing more profitable
work into other areas and there has to be some accountability and address for that as
some of the bigger centres tend to actually inherit the less profitable or loss making
areas.
So if there's only one area I could pick, it was the help with the national barriers.
>>Jeanette Watkins: A question from the [Inaudible] in the middle and then could somebody take
a mike to sound please?
>>Participant: I'm an official from the Royal College of Paediatrics and Child Health.
You mentioned some work regarding children's' surgery.
Could you elaborate, in terms of your programme, what you have achieved in terms of key standards
of care for children in the last few years and what your priorities going forward would
be?
>>Des Breen: We've got, we've got two areas of involving paediatrics.
One is the acute care, the physician element to it, which has just started, but we're actually
more ahead on the surgical services.
We developed a joint work stream with the commissioners.
We've had several workshops involving clinicians and nurses and allied health professions across
the whole region and this has been going for about nine months.
It's also been backed up by the recent publications of the paediatric standards.
So at the moment we have identified what are the key and core services for paediatric surgery
that could be provided in each local trust as a minimum and then when we've actually
got things that are non-sustainable, it's how we are going to redevelop that.
So for instance, a cut off for a fairly fit child, or from an age related point of view
from anaesthesia made from an age related point of view is very different to the cut
off for what an orthopaedic professional may be able to be expected to do in a district
general hospital.
And very much more, the more difficult one is about paediatric general surgery, where
the cut off for age related things for acute abdomens, for instance, is much higher, based
on the changing work force that paediatric general surgery has been stripped out on both
general, sort of, training.
So where we are at the moment, we've got a matrix because we've got so many principals
of programme but we want to deliver as much close to the patient as possible but then
redistribute and sort of, consolidate where necessary.
And so we have a matrix building up of what core services should be for paediatric surgery
in a district general hospital, from a minimum bar point of view, and then how we are going
to then deliver the rest.
And it doesn't always mean being centralized in Sheffield Children's Hospital.
>>Jeanette Watkins: So we have a question from Sam over here.
>>Participant: Hi, over here.
One of the challenges on days like today, you heard yourself, is everybody's saying
the same thing, so.
We're here to drive change, we want to collaborate and we're looking forward to [Inaudible],
not work across the local population.
So my question is what's your unique selling point?
Why you above all of the other 29 Vanguard applicants and in, kind of, less than three
lines.
>>Richard Jenkins: Sure.
I think there's no second chance at this point in the stage of the development of the NHS,
so I think the key issues for choosing Vanguards will be the potential for success and the
potential for replicability [Inaudible] across the NHS.
So whoever just thought of this for this Vanguard process, we started out thinking at 2012,
we established ourselves in 2013 and we have an established track record about being able
to deliver in this collaborative fashion.
So we think we've got a lot of things to share with the NHS, but equally to learn from the
NHS about taking things forward and that's with the best predictor for future success.
>>Jeanette Watkins: Final question, if we could just keep it very brief.
>>Participant: [Inaudible].
Just one question that I could have asked anybody today.
If all the [Inaudible] stages being that this is all being well accepted within the organizations,
there must have been resistance to change and with larger collaborations, that's going
to be greater, how'd you manage that?
>>Richard Jenkins: That's very interesting and certainly we, to take any of the clinical
models, for instance, we certainly involved the clinicians right from day one and that's
to include both the medics and the nurses and now health professionals.
We're not a programme about actually creating models and forcing down change.
All these changes have come from bottom up approach and essentially it starts off with
a workshop which we usually facilitate to make sure that the dialogue is dissolved.
And what we're trying to do is dissolve the clinical models and rebuild them, because
if you ask two hospitals, you're going to shed one service, which one do you want?
There will be a fight and there will be a winner and there'll be a loser.
So we're trying to actually devolve all that and we got quite skilled in the facilitating
mechanisms to be able to do that.
And the models are actually built up by the clinicians.
And then when we got the models built up by the clinicians and eye health professions
and patients and involvement, we actually have scoring mechanisms now which are well
developed to be able to just score them and then rank them.
Also, in many of our clinical services, we've already been out to external peer review,
the senate and local experts.
So we have done well.
So once we've actually got the clinical engagement, they create the models and that's been one
of the biggest hurdles we've learnt to overcome in getting [Inaudible] Because you know, it's
like change in a hospital can be difficult between clinicians.
Change amongst, for instance, 45 ophthalmic consultants across seven things is different,
but they really owned it and bought in to it.
>>Jeanette Watkins: I need to leave it there.
Thank you very much [Inaudible] Working Together Programme.
Thank you very much.