Turn to the findings page of any evaluation of new services that have tried to span organisational boundaries, and there is a high chance you will find an observation about time: more of it was needed to see results, not enough was factored in to the design phase and so on. ‘Allow sufficient time’ is a phrase so common in ensuing recommendations to policy makers it is at risk of losing its power.
As the NHS and social care batten down the hatches for what threatens to be a very difficult winter, time is clearly in short supply. It’s just over three years since the Five Year Forward View was published, with a radical vision for new models of care that were designed to relieve some of the pressure on hospitals by dissolving the barriers between health and social care. But at a national level, emergency admissions to hospital, the sentinel indicator of better coordinated care, are rising steadily.
Selected and launched in 2015, NHS England’s new care models vanguard sites were supported by a national programme which was designed to give time and space to support new ideas for complex change. The national programme ends in April 2018. Time is running out. There are some promising findings, such as those in the Improvement Analytics Unit’s national evaluation of a package of enhanced support for older people living in care homes in Rushcliffe, Nottinghamshire, and more evaluations are on the way.
As Nicole Bacon, one of the senior leads at Principia (the consortium behind the new care model in Rushcliffe) explains, the positive outcome of the evaluation so far is only a starting point for their team. With interventions that comprise many different components – from GPs working differently, to new roles for voluntary sector workers – understanding the active ingredients of change can’t be taken for granted and needs constant interrogation.
It will be a while before many of the other new care models can produce detailed evaluation findings. In the meantime, if professionals involved in implementing these new models of care had to explain, to patients in the ‘old model’ areas, why successful change takes so long, what would they say? While the answer to this wasn’t the primary research question behind Anna Starling’s report, Some assembly required: implementing new models of care, her research into the practical steps taken by those who’ve designed and implemented new services locally sheds interesting light on what soaks up so much time.
Successful projects need to build on the energy of what’s already there rather than duplicate ideas. But understanding what projects might have been tried locally is not straightforward. There is no directory of innovation, and people leading projects often took to the road, held well publicised meetings, or created new job roles to attract those willing to try new ways of working. Converting good ideas generated by a small group of enthusiasts into projects that make sense to a larger workforce also took up time, even with the support of NHS England. Add to this the challenges of building common ground between different professional groups, where underlying attitudes can be very different about what good care looks like, or what is a reasonable risk to take.
When a local health system is in a hurry to make changes happen, or is under pressure to show that change is happening, it’s tempting to create new organisations, put in place contracts or other infrastructure that is, at least, tangible. But as Samantha Jones (who led the new care models programme until May this year) explains, structural changes are pointless unless the people within them are willing to change their behaviour.
Changing behaviour requires acknowledging difficult things that can lurk underneath normal working routines, for example, power imbalances between different organisations and professions (think of the likely interactions between powerful acute trusts and financially threadbare social care services) but also the anxiety that comes from trying new things in a pressurised environment. A working example of this comes from one of our Innovating for Improvement projects, which has expanded access to hospice services for non-complex end of life hospice care in Leeds.
A close reading of what’s involved in a superficially simple idea – better access to hospice care – actually requires multiple people to step out of their comfort zone. These include hospital professionals who need to be willing to recognise that people might be at the end of life and refer to a new service: crucially, one led by specialist nurses. It also requires courage on the part of patients to express their wishes around care at the end of their lives and both patients and their families as well, to step out of an environment that might feel safe, such as a hospital ward, into something less familiar.
Recognising and holding intense anxiety is threaded through the day-to-day work of the NHS and social care. Changing routines, especially at a time of intense pressure, takes courage, and, it goes without saying, a lot of time.
Ruth Thorlby is Assistant Director of Policy at the Health Foundation. Twitter: @RThorlby