Collaboration and enabled leadership helped one trust achieve better integration of services, which ended up benefitting both the patients receiving care and the staff delivering it, writes Jane Wells.

In the London borough of Greenwich we recognised the commitment of our staff but also knew that our intermediate care and social care services were reactive and piecemeal. There were significant opportunities for better outcomes through integrated working.

Our vision was for one service, working across disciplines and sharing skills to improve outcomes for vulnerable older people and provide a collaborative and proactive approach for those with urgent health and social care needs. This required a change in culture, behaviour and attitudes.

The commitment to leadership

The leadership commitment for the future is to:

  • Constantly measure the impact of the new model. The outcomes were immediately measurable and clearly show: a significant increase in the number of referrals being addressed at the point of contact; reduced duplication; faster flows through intermediate care; and increased avoided admissions. Notably the focus on reablement, personalisation, choice and self care has reduced the need for long term care packages and supported longer independence at home. This reinforces that things are working.
  • Continue to obtain regular engagement and feedback from teams about what is working well and make ongoing improvements to the system and process.
  • Further integrate the systems and processes with other parts of the local healthcare system.

We took time to map processes and discuss potential opportunities to do things differently on a wide scale. Staff also engaged in problem solving workshops, such as working out where and why there were delays in the existing system.

Despite initial natural anxieties and fears, there was a desire from the front line to take control of the destiny of its services and respond to the challenge to redesign the model. A vision was collectively created and a collaborative approach adopted. A strong, committed group of team leaders came forward to engage staff from the top to the front line. A new design emerged with:

  • a single point of contact – incorporating referral pathways and immediately addressing user need;
  • a joint emergency team – fast, immediate responses to prevent hospital admissions and urgent social care referrals;
  • a hospital intervention discharge team – fast discharge to intermediate or social care;
  • community assessment and rehabilitation teams – up to six weeks of rehabilitation and ongoing social care linked with a home care reablement service;
  • proactive flow management through intermediate care beds with a collective key performance indicator so access and discharge is faster;
  • shared management and co-located teams of nurses, physiotherapists, occupational therapists, social workers and care managers.

Critical success factors that really supported engagement included a belief that good and meaningful engagement with staff leads to good design and great outcomes. This meant developing the vision with staff, accepting their natural resistance and fears about change, and building commitment to a shared vision.

The challenges

The biggest leadership challenges we face are how to:

  • Engage our committed and dedicated staff to deliver better quality care amidst competing demands and priorities
  • Ensure that we tap into staff members’ main motivations to deliver more excellent care while tightening resources
  • Support staff to recognise that, although they are doing a great job, there are always opportunities to improve quality, productivity and prevention through innovation
  • Focus on the delivery of value  through better quality and be more responsive in overcoming  the perceptions that change is driven by cost improvement programmes
  • Capitalise on staff creativity and skills in times of financial famine, recognising the impact of the psychological process of a change cycle
  • Find time and space to step back
  • Demystify service improvements for operations and processes
  • Keep stakeholders happy and meet their expectations

Enabling change

We fostered a willingness to change collectively the culture of the organisations involved through clinical engagement and development of a common language, leading to shared values, beliefs and altered attitudes. Facilitation needed:

  • exceptional leadership to develop and empower managers to be leaders and champions, and act as great role models;
  • joint governance and change management engaging staff at each step;
  • work based on the premise that anything is possible, with a constant focus on user experience;
  • the engagement of stakeholders including commissioners, patients, service users and staff unions;
  • workshops and external facilitation;
  • cross working with IT and teambuilding workshops to prepare for implementation and beyond.

Our staff must be valued, nurtured and respected. They are highly compassionate and intelligent with innate skills in problem solving and are driven by strong values. Ensuring we never lost sight of our fundamental values and purpose was vital when releasing potential. Connecting people built their confidence to shape their own destinies. Our leaders had to be self aware and authentic. When working across systems they are transparent and openly demonstrate trust and commitment to a common goal. Empowering staff in a different way was very liberating as they led people through the change process with empathy and emotional intelligence.

We aspired to create a culture in which morale, engagement and productivity are high. Feedback has shown that staff recognised the benefits and share a sense of satisfaction, recognition and value that further motivates them.

Oxleas Foundation Trust, in partnership with the London Borough of Greenwich, won the Staff Engagement award at the 2011 HSJ Awards.

The benefits: a case study

The impact on quality of life and efficiency is well illustrated by a case study of a 50-year-old, single woman with a neurological condition. She has had several falls, is unable to bear weight, uses a hoist to transfer and is doubly incontinent.

Until April she was having domiciliary care support three times a day from two people per visit. An assessment officer identified that the midday visit restricted her going out and she wanted to be able to change her own incontinence pads. Members of the new team put their heads together and the occupational and physiotherapist identified ways for her to change her own pad using a sliding board and upper body exercises.

Immediately the midday visit reduced to one carer to oversee and support her. She can now nearly change her own pad independently and the visit will stop. The service user outcome is greater independence and fewer support workers visiting. The cost reduction of one support worker is around £3,000 per year. There is also potential for further independence and cost savings.

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