The whole systems approach to integrating urgent and emergency care

There is a growing body of evidence to support NHS England’s chief executive Simon Stevens’s key message on integration within the Five Year Forward View.

More than ever, it is apparent that integrating health and social care leads to the achievement of the best patient experience and outcomes in the most cost effective way.

The NHS workforce as a whole is under considerable pressure, with reports of both existing and predicted shortages in many professional groups. The impact of staff shortages falls on the effectiveness of the urgent and emergency care system, which depends on collaborative partnerships with other services and specialties crucial to improving care pathways and outcomes.

Unrelenting pressures

The Royal College of Practitioners highlights a severe crisis in the recruitment and retention of GPs. Figures released in 2014 showed that 90 per cent of the GPs are over the age of 60 whilst many GPs are choosing to retire at the official age of 59 to pursue private businesses or work abroad.

“A survey conducted by the King’s Fund in 2014 demonstrates an ongoing failure of many NHS Trusts to recruit substantive posts, including leaders and frontline staff”

The unrelenting pressures arising from the workloads and limited resources are diminishing the desirability of careers in medicine. Current staffing levels in the acute medical units and emergency departments do not match service demands and patient needs, to reflect both the numbers of patients and the times at which they are most likely to attend.

A survey conducted by the King’s Fund in 2014 demonstrates an ongoing failure of many NHS trusts to recruit substantive posts, including leaders and frontline staff. The coping strategies have led to custom use of locums for frontline staff and highly expensive interims to steer and deliver services, putting cumulative pressure on acute trust resources.

The suspension of GP out of hours and NHS 111 procurements to allow for new plans on designing integrated urgent care services is bound to create further complications in signposting for urgent and emergency care services. This consequently rebounds people to the unnecessary use of emergency departments and hospital admissions.

Bold action

The worst hit are mental health services and acute hospitals, where the independent inquiry into acute and crisis mental healthcare in 2011 identified a limited skillset to care for people with multi-morbidities that span mental and physical health.

“In his call for ‘bold action to make the NHS fit for the future’, Simon Stevens mentioned the plan to convert agency staff - often obtained by holding the NHS to ransom - to permanent nurse jobs”

This can be attributed to the education and training model in England that produces graduates with different levels of experience and learning outcomes. If the current and future healthcare workforce will be the means of realising NHS ambitions, there is an urgent need for high quality learning and development for the next generation of health professionals.

In his call for ‘bold action to make the NHS fit for the future’, Simon Stevens mentioned the plan to convert agency staff - often obtained by holding the NHS to ransom - to permanent nurse jobs.

On face value this provides a quick win situation for numbers but questions about safety, efficiency and effective workplace culture remain unanswered. Although portrayed as best practice, the integrated models of care are unlikely to shield the weaknesses in much of the existing workforce.

What is a whole system approach?

The Department of Health distinguishes a whole systems approach as “not simply a collection of organisations that need to work together, but a mixture of people, professions, services and buildings which have individuals as their unifying concern and deliver a range of services in a variety of settings to provide the right care in the right place at the right time”. Contributions from interdependent stakeholders characterised a whole systems approach to urgent and emergency care as one that:

• Is safe, sustainable and person-centred based on best evidence and practice standards
• Integrates health and social care
• Focuses on quality and safety rather than targets
• Is tailored to meet needs of the local population
• Involves interdependent partners working together towards the same purpose

It is evident that strong systems and clinical leadership is essential in directing the realisation of whole systems integrated urgent and emergency care while coping with change. Whilst systems leadership is often presumed to be the remit of commissioners, ‘clinical systems leadership’ is presented as a new concept for the UK, linked to expertise in a number of functions around culture change that complement clinical credibility.

Clinical systems leadership therefore draws on expertise from different areas to facilitate contributing partners to work together towards a shared purpose and dismantling silos. This expertise therefore includes:

• Clinical expertise and credibility for a specific client group (with case management)
• Leadership to achieve culture change across primary and secondary care and partner organisations
• Developing, improving and evaluating person-centred, safe and effective care
• Advanced consultancy functions from client-centred through to organisational and systems levels to enable expertise to be spread to as many people as possible
• Creating a learning culture that uses the workplace as the main resource for learning, thereby maximising opportunities for learning, development, innovation and inquiry

Effective clinical systems leadership has an undeniable positive impact on workplace culture, ways of working, team work, staff wellbeing and satisfaction as well as the patients’ experience and outcomes.

Development work with leaders in healthcare systems completed by Advancing Quality Alliance (AQuA) and the King’s Fund in 2014 highlighted a discrepancy between ideas of how to develop systems leaders and the real investment in developing systems leaders.

Certainly the campaign to develop integrated approaches must be accompanied by an increase in the scale and pace at which leaders are developed at every level of the system.

Avoiding duplication

An integrated career and competence framework for a whole system approach demonstrates how interdependent partners across the NHS career framework provide complementary competences in different contexts and empowers career development and progression, not just for clinicians but also for support staff, including administrators and volunteers.

We identified three overarching domains performed in any context of interdependent systems partners located in patients homes/residences; primary or secondary, urgent and emergency care settings. These include ‘Assess’, ‘Treat’ and ‘SORT’ (supporting discharge, organising admission, refer and/ or transfer) within a value framework that focuses on providing person centred safe and effective care. We found that in order to avoid duplication of effort, these domains should be supported by a workforce aligned to a single competence framework.

Here we refer to competence as the actions informed by knowledge and skill of the role of the professional in the health care delivery systems. A single career and competence framework would offer optimum management of the patient pathway and experience in an interdisciplinary way underpinned by shared risk and integrated information systems.

”Commissioners are the passport holders to dismantling the prevalent culture of working in silos by introducing integrated strategies across the health and social care systems”

It would also provide a development framework that would contribute to staff retention. The framework needs to be supported by skilled facilitators that can draw on the workplace as the main resource for facilitating learning and development. Systems would need to steer away from ‘continuing professional development’ that focuses on individual capacity and embrace collective capability through ‘collaborative practice development’.

Silo working

Integrated models of delivering care have workforce implications for a number of organisational partners, including Health Education England, higher and further education institutions, health and social care entities and clinical commissioning groups.

In this vein, commissioners are the passport holders to dismantling the prevalent culture of working in silos by introducing integrated strategies across the health and social care systems, particularly in the use of budgets. In addition to supporting community, primary and social care services to master their role in a whole systems demand, the following recommendations will create a workforce apt for the future within integrated urgent and emergency care.

• Endorse and support the enhancement of an integrated career and competence framework across urgent and emergency care; support inter-professional learning and development; and a pathway that clarifies skills required linked to the NHS Career framework.
• Invest in an integrated workforce commissioning strategy for urgent and emergency care services across primary and secondary care, with links to higher education institutions.
• Establish in-service workplace rotational learning initiatives that focus on growing practitioners who demonstrate the competence to work at advanced levels in all disciplines so as to grow emergency practitioners. Develop and invest in joint appointments for systems leaders across primary and secondary care for effective leadership to create workplace cultures that sustain safer and person centred services in contexts where everyone can flourish
• Extend collaborative initiatives with Further Education Colleges to develop the role of support workers and create career development opportunities for volunteers and business administrators.

Kim Manley is an associate director for transformational research and practice development, East Kent Hospitals University Foundation Trust, co-director, England Centre for Practice Development, Canterbury Christ Church University; Anne Martin is research fellow; Carolyn Jackson is director and Toni Wright is research fellow at England Centre for Practice Development, Canterbury Christ Church University