Report for Kirkcaldy and Levenmouth CHP Committee.

Southcentral Foundation, Alaska: learning to date in Fife and implications for the future

Introduction

This report summarises a range of activity and learning which has taken place in Kirkcaldy and Levenmouth CHP and across Fife in relation to a model of healthcare developed by Southcentral Foundation (SCF) in Anchorage, Alaska. It includes a wide range of activity as the insights generated from studying SCF have been useful in different areas of work. Whilst the interest in the Muiredge Project has been considerable, there are many other lessons to draw from SCF and apply within the wider healthcare system.

The report discusses the implications of this learning for Kirkcaldy and Levenmouth CHP and NHS Fife more widely. Finally, some next steps are recommended. There have been contributions from a number of people in NHS Fife to the compilation of this report who are listed at the end. The author of this report thanks them for their time and patience and has attempted to represent their views fairly and honestly. However, in the end, this report is that of the author alone.

Background

In 2009, the model of healthcare developed by SCF was identified as having many of the features of the system needed in Fife if we are to adapt and respond to the pressures and strains in services. What was striking about the model was that it appeared to be substantially more effective than current ways of working and sustainable in the long term (better health outcomes for patients, higher levels of staff satisfaction, downward pressure on healthcare costs). Appreciation of the SCF “Nuka” model of care is growing. In 2012, the organization won the coveted Baldridge Award for quality services which was awarded to them by President Obama. In 2013, Don Berwick, founder and former CEO of the Institute for Healthcare Improvement, said the model at SCF offered a solution to the crisis that grips the US health system. These are serious endorsements for the model, suggesting it is world class and well worth learning from.

One of the reasons for this interest is that SCF has achieved a major reduction in hospital admissions (53%), referrals to secondary care (65%), attendance at A&E (50%) and use of primary care (25%) in ten years along with a reduction in the crime rate, domestic violence and unemployment. They have grown their model through “intentional design”, which (unlike “roll-out”) is constantly under review and improved through dialogue with the community they serve. In some ways, SCF has simply discovered British general practice in providing longterm continuity of care to a panel of patients. There are however striking differences. The first is the level of dialogue SCF has with its local community, encouraging them to take ownership of their health and healthcare system and includes strong representation of the community on governance structures within the organization. The second is the level of integration and cohesion between the different members of the primary care team which allows everyone to play their part, optimising the skills available. The third is the way SCF deploys demand-led systems, seeking proactively to find effective and lasting solutions for people seeking help. Making the decision to provide same-day access for patients was a bold step but in keeping with demand-led system design.

Such is the interest in the “Nuka” model across Scotland that in 2010, the Health Department and NES sponsored a visit from SCF. The four-person team spoke at the NHS conference and because of a successful bid to gain some time with them, they visited Fife for two days. They participated in a dialogue event at Cameron Hospital which was focusing on the reconfiguration of services for the care of frail older people with dementia and attended a “Blether” in West Fife which also focused on services for older people.

Reports and videos were produced of this visit and are available at the Playfield Institute website:

http://www.playfieldinstitute.co.uk/research/alaska_visit/alaska_home.php

The visit of SCF to Fife inspired a small group of staff (Tricia Boyle, Fiona Mackenzie, Swapan Mukherjee and Margaret Hannah) to fund-raise and visit Alaska in 2011. In June of that year, SCF were hosting their first international conference on the Nuka model of health.

The conference included a three-day training in “Core Concepts” which is run for all staff working at SCF. The training covered a wide range of dialogue techniques, helped us learn how to recognize our tendency to jump to conclusions (ladder of inference), deal with conflict and share stories in a respectful way. At the end of the three days, everyone shared their own stories within the confidence of a small group of other people. This experience helped us understand the power of story in forging trust and strengthening relations between people and its connection to health, maintaining it and restoring it.

A total of eleven people from across the whole of NHS Scotland have now visited SCF. More continue to make the visit. With encouragement from Jason Leitch, Director of the Quality Unit, three of these people presented the SCF model to Alex Neil, the Cabinet Secretary. As a result there is real interest in taking discussions further with clinical leaders across Scotland.

The Nuka model

The word “Nuka” is Alaskan Native and means “large, living structures”. Implicit in this word is the idea that living structures rely on healthy relationships to flourish. If we see healthcare as a living human structure, then it will thrive best when the quality of human relationships are good.

Further learning points from SCF include:

·  Good health can only be achieved in the context of good quality relationships, with yourself and with each other. It is therefore a shared responsibility between individuals, their families and healthcare providers.

·  Good health includes physical, mental, emotional and spiritual dimensions. Addressing one aspect in clinical encounters without consideration of the others is sub-optimal and will lead patients to seek more help for their problems. “Spiritual” in this context is not about religion, but about having a meaning and purpose in life and having opportunities to experience the joy of simply being alive.

·  Systems of care are human and operate according to the quality of human relationships – between staff and patients and between different members of staff.

·  Healthcare works much better when staff are working in fully integrated teams, where hierarchy is minimized, different roles are valued equally and everyone is working to the “top of their licence”.

·  At SCF, each integrated primary care team serves a discrete panel of “customer-owners” (the SCF term for patients) who they get to know and work pro actively with. This builds longterm continuity of care and quality human relationships into services. The core ‘product’ of these teams is not prescriptions, pills or equipment supplied, but empowerment to make healthy changes in one’s life.

·  Better clinical outcomes and staff satisfaction are achieved when staff ‘bring their whole selves’ to work. Staff need encouragment to work on their own health and wellbeing if they are to help their “customer-owners” work on their health effectively.

·  The relationship between staff and customer-owner is facilitative rather than telling them what to do.

·  Sharing stories helps people return to health and stay well. This includes staff as well as patients and when done in a safe, respectful way, is a powerful way to build trusting relationships.

·  For most people with chronic health problems, understanding what is going on in their lives is crucial for healthcare interventions to succeed. For example, addressing loneliness and other causes of languishing will give people the motivation to manage their multiple long-term conditions much better themselves.

·  Healthcare systems improve more quickly if clinicians are encouraged to share their good ideas constructively with others, rather than criticizing those who are not doing so well. Clinically relevant data can be used to identify good practice and learning from this, rather than focusing on poor practice.

·  Staff need to learn conflict handing skills and look at their own assumptions and story when preparing to resolve disputes with others.

·  Improvement methods provide the infrastructure to maintain and enhance service quality and support people to be better at what they do in a conducive learning environment.

National and Local Context

Integration of Health and Social Care

With the introduction of integration between Health and Social Care, the need to find common working principles for different staff and agencies becomes more important. Insights generated by the Nuka model of health are relevant for this task. There is also a new fund which could provide pump-priming to support further innovation along these lines in Fife.

NHS 20/20 Vision

The Route Map for implementation of the NHS 20/20 vision recognizes that primary care needs support to evolve new models of care. The Nuka model of care offers some helpful insights for this to happen. There is interest in the Primary Care Division of the Scottish Government Health Department to support primary care in Fife to develop new models of care, particularly where this is addressing the issues of multi-morbidity and builds on the strengths and assets in communities themselves.

NHS Quality Strategy

The NHS Quality Strategy puts person-centred care at the heart of healthcare practice. The lessons from SCF are relevant here too. There is a growing recognition in the Scottish Government Health Department, NES and JIT that staff need opportunities to develop their skills to engage in person-centred conversations with patients and their families.

Developments in Fife: Muiredge Surgery

On returning from Alaska in 2011, Dr Mukherjee began to undertake changes in Muiredge Surgery based on what he had learned. He was supported by the three others who went with him and also Maxine Jones, the practice manager. With funding support from Kirkcaldy and Levenmouth CHP, a pilot was set up to create an integrated primary healthcare team, based on a panel of 1400 patients, with an administrator, two case managers (experienced nurses in the practice), a GP (Dr Mukherjee) and (with a small additional amount of funding from the Scottish Government) a Behavioural Health Consultant (BHC). Maxine Jones subsequently went to Alaska in 2012 to attend the second International Nuka Conference and brought this further experience of the model to the Project.

The pilot project went live in June 2012 and ran for six months.

During the summer months of 2012, a student intern from University of Michigan was able to extract some baseline data from EMIS and undertake a questionnaire of staff in the project team to ascertain changes in activity as a consequence of the new model. The overall impact on workload was a shift from face-to-face consultations to more interaction with patients by phone. Patients and staff were happier with the model with greater responsiveness, access to advice and support being the main benefits. The GP was able to work more flexibly, spending longer with patients who needed more time with him. A poster summarising these findings was accepted to the RCGP conference in October 2012 and is attached.

However, as with many radical changes, there were challenges. The doctors involved had mixed views about its success. Part of the problem was the project team’s relative isolation from the rest of the practice. The team worked from a room upstairs in the surgery away from the hubbub downstairs. This isolation created something of a “them and us” feel, not helped by the fact that those involved in the Nuka team were singing its praises. The implication for those running the usual service was they were not doing a good job.

A further problem was stress on the GP who had to be on duty from 8am to 6pm without a break. The workload was very unpredictable. At times there were few calls, resulting in a combination of stress and frustration that they were not seeing patients, compounded by the thought that the rest of the practice was having to soldier on as normal. The Nuka team required four WTE staff to operate. According to one of the GPs involved, this represented 40 percent of the practice workforce for only 14 percent of the patients. However, further analysis of the staff allocation by the practice manager suggests otherwise. Only 19% of staff were working in the Nuka team for 19% of patients on their list. Such were the differing perspectives of those involved.

Business continuity had not been fully thought through before starting the project. If one of the team went on holiday or was ill, another member of staff from the main practice stepped in. There was also confusion over some Nuka patients – a few wanted to stay with their usual doctor, whilst others attended the surgery in the usual way rather than access the designated team. Whilst efforts were made to replace those that left the Nuka list with new patients from the general list, there was a perception that the team left the main practice short-staffed.

After six months the practice took stock of the situation and decided to change the way they worked. In the absence of further funding, the BHC role was discontinued and the partners decided that they did not want further work to foster relational practice.

The partners introduced some changes for the whole practice. They introduced phone triage whereby the doctors talk to the patient on the phone before deciding whether they need to come in to be seen. Because some problems that patients phone with can be sorted quickly over the phone, the GPs are now finding that when they provide the day-time on-call they no longer have a long list of patients to see. They also find that patients attend appointments more frequently with this system in place so DNAs have fallen, improving their use of time. The GPs would like to have a bigger skill-mix in their team, recognizing the value of the BHC and a senior nurse to act as a case manager. Finding ways to fund this sustainably will be a challenge but worth exploring.