In public sector, compared with private organizations, we have a multi-stakeholders perspective. Each public stake holder has its own legitimate expectations, which can differ from each other or even can be opposing. Some stakeholders have the perspective of citizens, interested in public values, and others will see the things from the customer's point of view, as users of public services.
This strategic document is intended to provide a comprehensive understanding of the challenges that NHS Enfield is facing in implementing programmes which will provide better quality care in Enfield borough, in accordance with the Revise NHS Operating Framework 2010/1011, and Lord Dazi's report High Quality care for all.
Local citizens and local communities deserve good health and have a right to expect responsive and high quality care from the NHS. The NHS has to respond to unprecedented financial pressure, a changing workforce and rising demands. In order to address this challenges effectively and efficiently, local NHS agencies have to introduce new integrated models of care, to focus on prevention and health improvement.
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In 16 December 2009 it was published the operating framework for the NHS for 2010/11 which sets out the priorities for the NHS. The five priorities are:
Improving cleanliness and reducing healthcare associated infections;
Improving access through achievement of the 18-week referral to treatment pledge and improving access (including at evenings and weekends) to GP services;
Keeping adults and children well, improving their health and reducing health inequalities;
Improving patient experience, staff satisfaction, and engagement;
Preparing to respond to emergency like an outbreak of pandemic flu, learning from the past experiences of swine flu.
In 21 June 2010 the Department of Health published a revision to the Operating Framework for the NHS in England 2010/2011, setting out a number of areas in need of immediate change. The document reflect the government's ambition to move towards a health service which puts patients at the heart of decision - making, and focuses on quality and outcomes, not processes, and with more devolved responsibilities. The revision is bringing significant changes this financial year and laid out the changes to NHS services necessary to be taken in order to drive up standards; support professional accountability, deliver better value for money and create a healthier nation. One of the main focuses in improving the healthcare services is to transform the way health and social care services support people with long-term conditions to live as independently as possible.
Lord Dazi's report: High Quality care for all: A framework for action indentified six key goals for local NHS to focus on: tackling obesity, reducing alcohol harm, treating drug addiction, reducing smoking rates, improving sexual health and improving mental health. The report demonstrated that current services did not meet the needs of the population; there was widespread inequality in provision and outcomes. For improving the outcomes and overall patient's experience, the report suggested developing of eight high clinical pathways:
Maternity and newborn care;
Children and young people;
Long term conditions;
End of life care.
Settings the priorities in implementing the pathways have to be done by each local NHS, having in mind the specific of local population. Implementing them will have a tremendous impact on improving the health of local population.
Considering the documents sets above, NHS Enfield have to reorganize the way that healthcare services are delivered in Enfield borough. The main prioritise for change are:
Developing polysystems that treat people closer to home;
Implementing and delivering care pathways specific to Enfield population.
2. Force Field Analysis.
Force Field Analysis is a method, developed by Kurt Levin, for listing and evaluating the various forces for and against a proposed change.
2.1. Drivers for change.
Global forces as a drive force have a direct impact on national public services and affect the domestic political, economic and social trends. Welch and Wong (1998) suggest that there are global trends for public reforms
The biggest driver for change in the health sector, not only in England, but all over the world is the rising population expectations. The population is expecting not just the services that are there when they need them, and treat them how they want them to, but the services that they can influence and shape for themselves. They will expect services that are influenced by the new technologies, services which will respond to their needs using techniques common in the private sector.
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Another factor for change is the demand driven by demographics. People are living longer than ever. Population in Enfield is approximately 290,000. Life expectancy for males is 77.2 and for female 81.5 which compares favourably to both the London ( 76.7 and 81.2). The population is very diverse with over 90 languages spoken in Enfield schools. This trend is set to continue with all ethnicities except "white" expected to grow over the next three years. The population is also changing with an expected increase in the numbers of people aged 45-64 of 8% by 2012. This is important as this is precisely the age-group in which long-term condition develop. It will be important to screen this population and implement interventions. The major causes of death are heart disease, stroke, cancer and respiratory disease which account for approximately 75% of deaths in Enfield. Source: NHS Enfield annual report 2010.
Addressing the health inequalities in Enfield borough is an obvious concern. In March 2009 Enfield had an unemployment rate of 6.7% and average income in Enfield is in the worst 10% nationally. In 2004 half of all families with children in Enfield had a net income of less that £20,000.
This masks large inequalities in the borough and is one of the key reasons that implementing the polysystem service and pathways are priorities for NHS Enfield.
Available at: http://www.enfield.nhs.uk. Accessed at 27 January 2011.
Increasing access to information and internet access is another factor that influences the need for change within our community. People are more able to quickly and conveniently find information about treatment and diseases. They want to manage their health "on-line", do their own researches, appointments, reflect on what clinicians have told them and discuss issues from an informed position. NHS Enfield challenge is ensuring that people are able to access reliable information.
Funding is one of the biggest challenges that NHS Enfield will have to overcome. The efficiency challenge up to 2014 remains critical for the future. The local plans which are now in place to address quality, innovation, productivity and prevention will need to deliver at least the level of savings required to meet the increasing pressure on the NHS and to release resources to meet demographic and demand pressures, and invest in any new priorities.
3. Emergent strategy.
Change can be planned or emergent. Change is planned when it is" the result of a systematic process of scanning the environment and determining the ways in which an organization must change" (Osborne and Brown, 2005, p.25). Change emerges in an organization when it is brought about by" changes in its environment that are outside of its control" (Osborne and Brown, 2005, p.25).
As Lord Dazi address the challenges of change within the NHS, and he noticed that change must not be imposed by above, it must be locally - led, responding to the needs of local communities. He recognises that different places have different and changing needs, and the local clinicians are best placed to understand and respond.
NHS Enfield in accordance with these findings and in response to the patients needs, will have to deliver more outpatient appointments and carry out routine and straightforward procedures in GP practices, where appropriate.
The approach for managing change at NHS Enfield organizational level will include:
Readiness Assessments - creating the strategy that will change the services provided;
Sponsorship - engaging the senior managers as change leaders.
Communication - building awareness of the need for change.
Education and training - developing competencies and knowledge to support the change.
Coaching by managers - helping employees move through the transition.
Measurement system, rewards and reinforcement - methods to sustain the change.
3.1. Developing of polysystems structures.
A polysystem is a clinically-led network of care. They will deliver a broad range of services: urgent care, diagnostics, primary and community care, planned care, long term condition and case management. They will support extended opening hours and improved access. These settings will also provide a platform for further integration of health and social care, primary, acute and mental health services in a patient - centric manner which is closer to the user's home.
Lord Dazi's report suggest also that the implementation of the pathways to be facilitated by the development of distinct models of provision of care. Primary and community services, including significant aspects of urgent and planned care, will be delivered from polysystems. Ensuring integration and cohesion between primary care, secondary care and social care will be increasingly important in delivering high quality services to all.
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Implementation of polysystem structures in Enfield will facilitate grater access to GPs and deliver a broader range of services in community settings through co-ordinated pathways of care in line with Healthcare for London programme.
The actions to be taken are:
Development and implementation of effective commissioning arrangements based within 4 polysystems areas.
Developing new services and pathways in the Edmonton polysystem based around Evergreen Health Centre "joint hub" (areas of highest health and social need) for roll out across the Borough. This area has the highest health and social needs in Enfield and the next step will be to develop a model that indentifies the potential services that could be tackle the conditions and social needs prelevant in the area. Roll out of polysystems in the Borough will run parallel to improving pathways of care with local stakeholders.
Developing a premises infrastructure strategy that allows the introduction of more services. The work is going to be done in close co-operation with the Place Shaping strategy in Enfield Borough Council.
Aligning GP contracts to deliver high quality primary care.
These actions will lead to:
Improve access with longer and more convenient opening times;
More services available, including diagnostic tests and consultant input in practices;
Improved pathways of care where patients don't need to go to hospital so often;
These pathways will include more services for long term conditions and reduce inequalities;
The proposed model supports the Healthcare for London polysystem structure where by each area of Enfield will have a polysystem "hub" supporting surrounding 'spoke' practices. Practices within the polysystem can refer to any service introduced in either the hub or spokes and in some cases where it would be more economical. Gps from across the borough could refer into one polysystem service.
Improving long term condition pathways is a priority for NHS Enfield, in the context of the NHS London pathways and in accordance with the specific borough population. The following actions are proposed to take place in order to provide integrated healthcare pathways:
Rehabilitation services for major LTCs: respiratory, stroke and cardiac disease;
Acute Home Care service that enables patients to remain in their place of residence when a crisis has arisen;
End of life service that supports patients to die at home. This improves choice for the terminally ill and their families and will enable them to receive seamless, comprehensive care and access to advice and support 24/7.
Evidence states that the provision of rehabilitation services supports the reduction of readmissions and improved quality of life for the patients. We have existing pathways for heart failure and respiratory care, but neither had rehabilitation services as part of those pathways.
The National Service Framework groups for CHD, respiratory disease and stroke all strongly support the provision of rehabilitative services. The NICE guidelines for CHD state that the optimum cost for CHD rehabilitation is £550 per patient. Enfield NHS had 314 acute admissions for MI in 2007/2008. It is estimated that approximately 10% of those were as a result of second MIs. The cost of provision for these patients would be £173,000 per annum at the NICE advised rate. The focus will be on reducing disability, improving patient's mobility and quality of life in an appropriate community environment. This service will support Lord Darzi's report in that community services will be built around the needs of the individual not the service.
Resister of change.
In order to change any NHS services four tests must be met. These tests are measuring:
The support for change by local commissioners;
Plans must be based on sound clinical evidence to improve outcomes for patients;
Strengthened public and clinical engagement on any proposal are present;
Patient's choices of where to be treated were considered when deciding how local NHS services should be arranged.
To meet these four tests a series of consultation will be carried out by the end of March 2011.
As more health care in provided at home or closer to home along agreed pathways of care, it will be essential to ensure that all the health professionals involved have access to an up to date patient record. IT system will have to support integrated care across Enfield borough. The main actions that will facilitate polysystem development are:
A rollout of the Summary Care Record - to be completed by May 2011.
A rollout of image exchange systems between hospitals and potentially polysystems. This will enable consistent patient care, for example between hyper acute stroke units and their networks - this will be implemented by April 2011.
Polysystem appointment systems - to be implemented by the end of 2011.