Learning from CQC System Reviews

Wednesday 12 September

18 Smith Square, Westminster, SW1P 3HZ

#LFCQCSR

CQC: ‘Our experiences of the Local System Reviews’

Alison HolbournDeputy Chief Inspector, CQC

#LFCQCSR

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Alison Holbourn, DCI for PMS and Integrated CareLearning from CQC local system reviews, 12 September 2018

Beyond barriers

How older people move between health and social care in England

Our purpose

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We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve

Why did we carry out these reviews?

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• Secretaries of State asked CQC to undertake a programme of targeted reviews in local authority areas

• Reviews sat outside CQC’s usual legal powers (under Section 48 of the Health and Social Care Act)

How did this fit with our usual work?

Also built on our previous programme of ‘place reviews’:

• 2015/16 – North Lincolnshire, Tameside, Salford

• 2016/17 – Cornwall, London Borough of Sutton

Reviewing local systems reflected key findings of recent reports including:

•State of Care 2016 & 2017•Integrated care for older people

Scope and approach of the reviews

• Three ‘spheres’ and ‘pressure points’

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1. Maintaining the wellbeing of a person in their usual place of

residence

2. Care and support in a

crisisAdmission to hospital or alternative

3. Step down• Return to usual

residence• Admission to new

residence

• People aged 65+

• Focused on health and care interfaces

• Consider system performance

• No ratings

Where have we been and what have we delivered?

20 site visits

Beyond Barriers report – July 2018

20 local system reports

Interim report

December 2017

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A system designed in 1948 can no longer effectively meet 2018 needs

• Living longer – but with more complex health problems

• Increasingly, our care must be delivered by more than one person or organisation

• In 2018, we expect care to be personalised to people’s individual circumstances

• A fragmented health and care system designed in 1948 can not meet the needs of today’s population or operating environment

• We must remove the barriers to collaboration at a local and national level and create an environment that drives people and organisations to work together

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What we found 1/2

• People experience the best care when people and organisations work together to overcome a fragmented system

• Dedicated staff regularly going beyond the call of duty

• There were examples of good practice in every local system we looked at

• Where local leaders share a clear vision, it provides a shared purpose for people and organisations across the local health and social care system

• But in a fragmented health and social care system there are barriers to collaboration at a local and national level

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What we found 2/2

Funding: Health and social care organisations are limited in how far they can pool resources and use their budgets flexibly across prevention, social care and healthcare

Managing performance: Organisations are held to account for their own performance, not the performance of the system as a whole

Workforce: Services do not always have the right staff, in the right place, at the right time – the health workforce and social care workforce are seen as separate entities

Oversight: Regulation usually looks at quality of care in individual providers, rather than across a system as a whole

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1. An agreed joint plan that sets out how older people are to be supported and helped which in turn, guides joint commissioning decisions over a multi-year period

2. A single framework for measuring the performance of how agencies collectively deliver improved outcomes for older people

3. The development of joint workforce plans with more flexible and collaborative approaches to staff recruitment, retention and development

4. New legislation to allow CQC to regulate systems and hold them to account for how they work together to support and care for older people

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Recommendations to local and national leaders, and government

Three further reviews:• Leeds• Staffordshire• Reading

Follow up reviews:• Stoke-on-Trent• Oxfordshire• York

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Extended review programme 2018

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Thank you

www.cqc.org.uk/beyondbarriers@CareQualityComm

#beyondbarriers

‘The East Sussex Experience’

Keith HinkleyDirector of Adult Social Care and Health, East Sussex County Council

Bianca Byrne Head of Policy and Strategic Development, East Sussex County Council

#LFCQCSR

CQC Local Area Review

Reflections from East Sussex County Council

Background and Process• Between October 2017 – January 2018 East Sussex participated in first

round of Local Area Reviews , the focus of the review was the interface between health and social care and the outcomes for older people moving through the system .

• There was an assessment of the governance in place for the management of resources and of commissioning across the interface ; specialist commissioning and mental health services were out of scope.

• CQC reviewers visited East Sussex twice to meet with system leaders; hold workshops with people who use services, carers, and independent and voluntary sector providers; visit acute and community hospital sites, intermediate care sites, walk-in centres, a residential home and local hospice; and hold focus groups with staff from across the system.

• The draft report was received at the beginning of January, with an opportunity for the system to provide comments on f actual accuracy . The final report was subsequently received by the system late January.

• Following our East Sussex summit we have developed our Action Plan, which has been signed-off by all parties and is now being implemented.

Reflections on Review Outcomes • Provided system with an opportunity to review performance, celebrate

successes and refocus energies on areas for further development.• In East Sussex we have two integration programmes:

� East Sussex Better Together� Connecting 4 You

• Comprehensive programmes of change focusing on whole system through integration, prevention, pro-active care and building holistic care with local communities. For East Sussex Better Together this programmes includes the acute trust, which also includes community health services.

• For East Sussex Better Together the strategic aim is to fully integrate commissioning of services and delivery of care and an Alliance Agreement is in place.

• Performance, particularly against delayed transfers of care, had worsened over a period of 18 months.

Reflections on Review Outcomes• Appreciated acknowledgement of strength of shared vision and purpose, maturity of relationships, and

focus on prevention and support for people to maint ain their wellbeing.• In a challenged system this has reinforced the need to develop whole system and sustainable solutions

and continue work to deliver our shared goals.• The balance will need to continue to be struck between good performance and immediate challenges

and those longer term system objectives.• Recognition of more work required to accelerate plans to deliver High Impact Change model,

enhanced market capacity, and improved discharge processes.• Findings have informed reprioritisation of capacity and resource to ensure clear line of sight on

delivery and continued progress towards meeting key indicators and outcomes.• The outcomes of the review have continued to inform organistaional and system planning.• Alongside this we are also reviewing our governance arrangements through the Health & Wellbeing

Board

System Strengths• Joint Community Rehabilitation service has supported over 7,000 people

- 77% of whom have been helped to stay at home with no need for ongoing support

• Crisis Response Team (ESBT) supporting system to prevent unnecessary hospital admission - plans underway to develop a Rapid Response Service in HWLH area

• Hospital Intervention Teams and GP Streaming are in place at both acute hospital sites in East Sussex and at other hospitals supporting local residents.

• Daily calls and weekly MDT meetings set up to manage delayed transfers of care (DToC) across the system

• System-level escalation procedure to manage risks to service delivery when urgent and emergency care services are under pressure

• Improving capacity in the market through supplier relationship programme, increased fees for domiciliary care provision and exploring new care models

Discharge Processes• We have installed integrated systems to enable ESHT Acute Care, GPs and

ASC to view a shared portal with information regarding admissions, discharge and transfer, pathology and patient demographic data

• Recognised more work to do to fully embed the Lets Get You Home policy and improve communication with patients, families and p roviders

• Discharge to assess has been introduced in front door services in hospital, A&E and Clinical Decision-making Units (CDU) serving East Sussex., and we are now rolling out the programme hospital wide.

• We are now prioritising work to fully incorporate the principles of the High Impact Change Model, including implementation of the Trusted Assessormodel

• Joint working between health and social care has resulted in significant improvements to patient flows across the systems , acute and community providers

Delayed Transfers of CareActual Target

Apr-17 108May-17 93Jun-17 82Jul-17 89 77Aug-17 79 69Sep-17 80 62Oct-17 66 54Nov-17 56 50Dec-17 44 50Jan-18 42 50Feb-18 57 50Mar-18 42 50Apr-18 45 50

Delayed Transfers of Care (average daily delays)Actual Target

Apr-17 108May-17 93Jun-17 82Jul-17 89 77Aug-17 79 69Sep-17 80 62Oct-17 66 54Nov-17 56 50Dec-17 44 50Jan-18 42 50Feb-18 57 50Mar-18 42 50Apr-18 45.2 39.8May-18 43.7 39.8Jun-18 39.5 39.8Jul-18 44.1 39.8

Local Area Performance Metrics

Learning from Review Process• The approach taken to the reviews strongly reflected the stated methodology with the focus on

outcomes and whole system working in its broadest sense.• The clarity in the objectives of the review supported the whole process of the review, including the

framing and understanding of the report recommendations.• This experience was reflected elsewhere in the reviews undertaken in the south east.• The review process has contributed positively to improving outcomes in East Sussex.• There are challenges:

� Even with clearly defined parameters the reviews are inevitably complex, particularly in county areas with multiple systems

� The appropriately holistic nature of the work has meant a wide range of reviewers and this has led to duplication

� Looking more broadly across the south east there has been some variation in the level engagement from all area partners in preparing for the reviews

Learning from Review Process• Dedicated resource required to support review process, in East Sussex

this was managed by a small team (Assistant Director, Head of Service and Administrator).

• Time spent on communicating as early as possible the purpose and timeframes for the review supports partners to prepare and be engaged fully in process.

• Governance arrangements supporting the review should include all key system partners (e.g. acute and community health providers, CCGs, ambulance trust) and this contributed significantly to the sense of shared endeavour.

• Workshops with system staff on pressure points prior to the review generated and facilitated learning , and provided staff with helpful opportunity to reflect.

• Significant amount of time and resource required to plan, coordinate and support both site visits.

• Considerable work required to undertake factual accuracy and respond to initial draft report.

• Action Plan developed through Local Improvement Sum mit (oversight through Health and Wellbeing Board, SCIE and DHSC), requires resource to oversee and report against delivery.

Learning from Review Process• In terms of Sector Led Improvement there are a number of key developments within the South East

ADASS region:

� Sharing of learning between areas where review have taken place and are planned� Broader sharing of best practice� Inclusion of key metrics in the regional performance monitoring and benchmarking� Peer Reviews: all south east councils will now have a regional ADASS Peer Review which reflects

CQC methodology, with an opportunity to focus on areas of greatest risk and need for development

• This work is now built into the South East ADASS Regional Programme.

‘The Sheffield Experience’

Phil HolmesDirector of Adult Services, Sheffield City Council

Nicki DohertyDirector of Delivery, Care out of Hospital, Sheffield CCG

#LFCQCSR

“The Sheffield Experience”

Nicki Doherty, Director of Delivery, Sheffield CCG

Phil Holmes, DASS, Sheffield City Council

12th September 2018

What we’ll talk about today

1. Process (a bit) including managing communication

2. Improvement

• Micro view: the experience of our older people and our

staff

• Macro view: shifting our system towards prevention

Blindingly obvious summary of

CQC Review Process:

you get out what you put in

A note about communication

• CQC focus areas, from well-being, to crisis management to step-down, shone a light on our whole system

• We set up the review to allow CQC full access to our services, engaged widely with staff and stakeholders, and encouraged people to be extremely open and honest

• We used the review to celebrate the hard work of our staff and to highlight excellent areas of practice

• We also used the review to generate greater urgency about improving where we need to

• We tried to maintain this balance between celebrating what works and fixing what doesn’t so that we kept the faith of both local people and our hardworking staff

• Improvement is much easier if morale is maintained. We put a strong focus on communication to try and ensure this

Summary of a few manic months

1. Hard to argue with being chosen: our metrics tell our story. Scope broader than DTOC

2. The review focus is on the experience of older people. CQC pursued this with integrity

3. Some NHS colleagues took time to trust the process as they are used to CQC in other guises. Easier for Local Authority because it felt like sector led improvement

4. Very well managed process but a lot of (partnership) work to resource it

5. CQC views of Sheffield are sound, but report could have more clearly linked judgements to evidence

6. However the big challenge isn’t to CQC. It’s to Sheffield: can we understand and own our need for improvement?

Can a system with comparatively high

admission rates, long hospital lengths

of stay and people less likely to still be

at home 91 days after reablement be

providing a good experience to many

older people?

Using experience to drive change

1. CQC Review implicitly challenged us to have a qualitative perspective and grip as a system

2. We didn’t have this. Our golden thread in relation to ensuring good experience wasn’t very golden

• We didn’t come together as a system and listen to older peoples’ experiences of needing health and care

• Front-line staff could feel disenfranchised and unclear about what “the system” was aiming to achieve

• Focus of the Health and Wellbeing Board wasn’t sharp and “the system” wasn’t effectively being held to account

3. Therefore a significant part of our improvement plan is about fixing this (culture, practice, priorities) at all three levels

4. This is a fundamental challenge to Sheffield where we have mainly come together to talk about numbers

Investing in what works

1. High admission rates plus long length of stay plus large reablement service = lots of capacity for crisis management

2. Sheffield proud of various progressive initiatives that are intended to provoke shift to prevention, but lack of scale and pace: feel like pilots

3. Insufficient evaluation at system-level and historical foundering of new initiatives once funny money runs out

4. Insufficient joint working with our excellent Voluntary, Community and Faith sector

5. Our action plan picks up on all the above, and also uses our successful application to the Outcomes Fund as a means to pump prime mainstreaming of preventative model across the board

6. But there are tests to come. Will we be able to disinvest in crisis management capacity that is not needed, and reinvest in a sustainable system?

So in summary

1. CQC’s review methodology is value-driven:

• A system that incentivises prevention and well-being and disincentivises crisis

• A system that values every interaction with older people and prioritises practical

support for staff to turn theory into reality

2. If our system had already acted according to these values we almost certainly wouldn’t

have been a bottom 20 performer

3. Turning around the leadership behaviours that have resulted in us being a bottom 20

performer will take time

4. Having a review provokes reactive behaviours. We’ll know we’re there when we drive the

right values and build the right model of care even when CQC aren’t watching

‘The Hampshire Experience’

Graham AllenDirector of Adults’ Health and Care, Hampshire County Council

Jo LappinInterim Assistant Director for Older People and Physical Disabilities, Hampshire County Council

#LFCQCSR

Learning from the Hampshire CQC Local System Review

Graham Allen, Director of Adults’ Health & Care

Jo Lappin, Interim Assistant Director for Older Peo ple and Physical Disabilities

Purpose

• The purpose was to better understand the pressures and challenges and identify any areas for improvement needed in health and social care services within the local system.

• The review focused on services for people over 65 and whether people using local services are provided with safe, timely and high quality care.

• The following questions were explored:

• How do people move through the system and what are the outcomes for people?

• How well do social care and health partners work together in the local area?

• How can this improve and how should it improve?

Preparation; immediately establish a core team and plan down to the smallest detail –

no surprises and be able to respond The review took place over six weeks

Local Authority Strategic Project Team

Health and Wellbeing Board Extraordinary meeting/s

Key System Partner regular meetings and communication

System Overview Information Request (SOIR)

Briefing notes, FAQs and leaflet.

Case Tracking

Inspection team visit packs

Logistics e.g. drivers

2 and 5 day visit time table coordination

Relational Audit sent by CQC to Hampshire system

Field Work – 2 day visit; identify and begin to showcase – be open and inclusive

• In week three a team of six inspectors and specialist advisers undertook a two day visit to Hampshire.

• To enable full coverage of the county the team was split into three teams of two and they visited the following services.

• Hampshire was the largest and most complex health and social care system reviewed to date by CQC.

• Feedback from the two day visit informed which areas the review teams would focus on in the five day visit.

• Excellent service provision was seen / positive client feedback.

• Providers gave open and honest feedback.

• Appreciation that known issues and challenges were being addressed.

• Individuals’ experience is dependant on locality and may therefore not be consistent across Hampshire.

Two day visit feedback – our experience

Field Work – 5 day visit; plan, brief and prepare!

• A team of sixteen inspectors and specialist advisors, split into four teams to enable full county coverage.

• A complex timetable for each team.

• Visits to:• Acute hospitals• Ambulance providers• Out of hours service • GP’s • Hospices• Community Hospitals• Focus Groups • System Leader

meetings

Response

• At the end of the five day visit an initial feedback session was given to system leaders. This took place on the 12 March 2018.

• CQC draft report received 9 May 2018.

• Factual accuracy and feedback given.

• Final CQC report received 16 June 18.

• System summit held 20 June 18.

• Hampshire Action Plan response sent to CQC 20 July 2018.

Some observations…

• The methodology is robust, but potentially too rigid for complex systems; develop appreciation of local context and geography with CQC team

• The choreography can be difficult; LSR happening alongside individual NHS partner CQC inspections – managing BAU alongside thematic work

• The process is demanding, but made much more complicated given the multiple organisations involved; get buy-in from all partners early and maintain it throughout

• Final report and process of action plan development – build upon what is already happening and drive improvement; use the LSR findings!

W1. Maximising the impact VCSEs can have in a health and social care systemKate DrakeIndependent Living Operations Manager for the South East, British Red Cross

Jon VangorphBusiness and Partnerships Development Manager and Independent Living Operations Manager, British Red Cross

Phil HolmesDirector of Adult Services, Sheffield City Council

Nicki DohertyDirector of Delivery, Care out of Hospital, Sheffield CCG

#LFCQCSR

British Red Cross

Maximising the impact VCSEs can have in a health and social care system

What the CQC reports say about VCSEsCQC highlight a number of ways in which the impact of VCSEs in Health & Social Care Systems might be increased:• VCSEs should be more involved in planning for surges in demand throughout the year• VCSE sector workforce should be better utilised• Information sharing with VCSE services at a point of crisis should be improved• Reducing uncertainty around VCSE funding, as this hampers future service planning

However, there are lots of positives and good practice to build on:• Many VCSE services are working in a person-centred way alongside partners• VCSEs are often co-located alongside key partners• VCSEs can be prominent and equal partners in service development• System leaders value support from the VCSE sector and often feed that back

An example: Winter Pressures 2018Between 1 January and 31 March 2018 the British Red Cross supported 2,057 people through its winter pressures programme in 13 NHS hospitals in England.

1,392 hours were spent by Red Cross staff and volunteers supporting people in hospital

1,505 (73%) people were taken or escorted home from hospital

958 (47%) people were supported in their own home at least once

878 (43%) people were supported through at least one phone call

Through the hard work of our staff and volunteers we achieved 131% of our target.

Once our services ended we conducted a partner survey across all 13 sites to measure what hospital staff felt about the impact we made. We reported that:� 92% of respondents felt the services reduced delayed transfers of care or delayed discha rges� 100% of respondents felt the service would be beneficial to hospitals and patients if it ran next winter� 50% of respondents felt the services helped prevent unplanned re-admissions� 54% of hospital staff surveyed felt the services helped prevent unnecessary hospital admissions

Using our most conservative estimates we have calculated potential cost savings per person in avoiding one excess bed day to be £108 per person (based on an excess NHS bed day costing £313 and our support costing £205 per person).

Impact of our support

Thank youFor more information please contact:

Kate DrakeIndependent Living Operations Manager, South East of England KDrake@redcross.org.uk

Jon VangorphBusiness & Partnership Development Manager for Independent Living and Crisis Response, LondonJVangorph@redcross.org.uk

We prevented delayed transfers of care and delayed discharges� 92% of hospital staff surveyed felt the services reduced delayed transfers of care or delayed discharges� 76% believed this impact had been ‘significant’“As Red Cross have been able to get patients home qu icker than hospital transport, this has prevented delays in discharges to home in time for package of care to start”

We prevented unnecessary hospital admissions� 54% of hospital staff surveyed felt the services helped prevent unnecessary hospital admissions� 36% believed the impact had been ‘significant’� Of the 287 people referred to us from A&E, we prevented 72 people (25%) from being admitted“Patients referred to [the Red Cross] reported very positive contact and felt they were willing to go that extra mile. I used the service as knew they wou ld respond more positively than other services.”

Potential cost savingsPotential cost saving per person to avoid one excess bed day was £108 per person. This is based on one excess NHS bed day cost at a national average of £313, and Red Cross support costing £205 per person.

Impact of our support

We reduced unplanned re-admissions� 50% of respondents felt the services helped prevent unplanned re-admissions� 33% of respondents believed our impact had been ‘significant’� We supported 199 people where an unnecessary admission within 3 days of discharge was prevented. “These professionals [from the service] have been ab le to take patients home and ensure their safety, settling them into their home, ensuring foo d, heating and drinks available. Most of these patients would have remained in hospital overnight. ”

We created or strengthened good relationships with NHS hospitals� 100% of respondents felt the service would be ‘beneficial’ or ‘very beneficial’ to both the hospital and

patients if it ran next winter� 93% thought the flexibility and range of activities undertaken was ‘good’ or ‘very good’� 98% were ‘satisfied’ or ‘very satisfied’ with the service“The most compassionate and caring team of professio nals I have had the privilege to work with. Patients are at the heart of everything they did”

Impact of our support

Cornwall Royal Hospital Jon recently moved to Newquay where his social networks shrunk. After an extended period of unemployment he finally found a job but soon after fractured his ankle and was admitted to hospital for treatment. After a short-stay in hospital Jon was discharged and within days was visited at home by the hospital’s Early Supported Discharge team. They discovered him at home alone with no food, no electricity, no heating, and no money to resolve these issues. Jon was therefore re-admitted as a failed discharge.

What We Did� We were asked to help transport Jon home and facilitate his JSA for his second discharge home� Pre-discharge our team contacted the local foodbank ‘Transformation CPR’, to arrange some provision of food, and money to finance

electricity� Once agreed we mobilised volunteers to collect 2 weeks’ worth of food parcels, in addition to £40 for electricity and transport� Our volunteers took Jon home, settled him in, demonstrated what meals he could prepare with the food parcels, assisted him in

placing money onto an electricity key and liaised with Volunteer Cornwall to arrange community transport so he could reach his first appointment at the fracture clinic

The Difference We Made� This project demonstrated how, combined with a number of factors, a single accident can have significant complications to how an

individual lives their life.� We enabled the core issues to be addressed as Jon, and some others, saw them� Assistance from the volunteers allowed Jon to have access to food, to be comfortable living in his own home, and to continue his

recovery by reaching his follow up appointments.� This intervention helped Jon in a critical moment whilst alleviating pressures on health care services that dealt with the re-admission

and delayed transfer of care.

Case Study 1

Portsmouth Queen Alexandra Hospital - Enabling Disch arge Case Study Graham had been admitted to hospital after falling down the stairs. As he fell, he injured himself and his wife in the process. The wrist injury to his wife meant she was more restricted in the care she could provide to him along with the needs of caring for his dementia.A Staff Nurse on the FIT team at QA referred Graham to the British Red Cross to help enable a faster discharge. Having been admitted Graham was now medically fit but had nowhere to sleep in his home because negotiating stairs presented a significant additional risk.Graham and his wife planned to live downstairs for the short term but they were keen to get a stairlift eventually, to regain full independence. Hospital staff deemed it not safe to discharge Graham until his living arrangements had been adjusted. Graham’s wife and carer was unable to undertake this herself.

What We DidBritish Red Cross discussed the case with the sister in charge and agreed to put in place low level support to facilitate Graham’s discharge.It was agreed some basic adaptations would mean that he could safely transfer himself into bed. BRC team confirmed immediate capacity to help enable the discharge. This saved several bed days for the hospital and enabled Graham to return home to continue his recovery.Two Red Cross support workers met Graham and his wife and carer at home that same afternoon. Using Trusted Assessor training andlistening to the couple’s needs they worked together to make improvements and low level adjustments to the living room. A temporary bed was installed with a suitable bedrail for Graham's size and weight and the bed was made up for him. Furniture in the room wasrepositioned to order to allow for space and safe transfer to the bathroom and living area. The BRC team also discussed the activities that Graham and his wife enjoyed doing and talked about how they could continue with these and what extra considerations they would need to take into account to help get their independent lives back. With Graham and his wife settled in they had more confidence that things could return to normal and get a better night’s sleep.

Case Study 2

Follow upRed Cross telephoned the next day to ensure everything had worked out. The couple informed the support worker that they had both had a reasonable night’s sleep. Both Graham and his wife were appreciative of the support they had been given. There were plans for a relative to visit and help out in the coming weeks. They were also expecting a package of care to begin that evening.

Red Cross continued to support the couple at home and helped them to obtain quotes for the installation of a stairlift and provided information and support for their decision over the telephone.

The Difference We Made• We freed up a bed and nursing/OT time earlier than would otherwise have happened• We got Graham out of hospital and improved his chances of recovery to independence• We supported Graham’s carer and helped him to avoid unplanned readmission• We looked at the couple’s non-medical needs to help with their quality of life

Case Study 2

W3. Getting the measure of relationships

John AshcroftResearch Director, The Relationship Foundation

Graham AllenDirector of Adults’ Health and Care, Hampshire County Council

Jo LappinHead of Safeguarding and Governance, Hampshire County Council #LFCQCSR

Workshop 3

Getting the measure of

relationships

12th September 2018

Relationships in local systems

• What did we learn or hear this morning?

Context: Why a relational audit?

� CQC key lines of enquiry to understand how well led the system is:

• Shared, clear vision and credible strategy

• Impact of governance on health and social are interface

• System approach to workforce

• Commissioning within the local area

• Resource governance assurance

Relational Risk

• How might relationships within a system compromise these goals?

Relational Value

• What are relationships within the system creating that enables these goals to be achieved and sustained?

Question?

What leadership behaviours are needed to work effectively

across an integrated health and care system?

Audit would provide:

• A common framework;

• Common understanding of strength of relationships in the 20 systems under review;

• Identification of strengths and areas for improvement in relationships;

• An ‘ongoing’ method of assessing those relationships;

• Greater potential to drive forward joint agenda and improve outcomes for local people.

How?

• Co-creation of a bespoke audit or ‘scorecard’;

• 35 statements, to be rated on a 6 point scale;

• Anonymous;

• Some demographic intelligence;

• Opportunity for free text comments;

• Completed using an online tool disseminated locally by stakeholders;

• Analysed by CQC.

Outputs - general

• More than 2500 responses across 20 systems;

• Findings suggested some key lines of enquiry for site visits;

• ‘Rang true’ with what was found on the ground;

• Gave a language and a legitimacy to conversations that may otherwise have been seen as ‘soft’ impressions

Specific findings

• Possible disconnect within and across health and care organisations;

• Organisational and staff changes slow progress;

• Financial and resource pressures impact relationships, shared vision, joint working;

• Blame culture and reluctance to take risks for fear of criticism;

• VCSE organisations rated relational health lowest;

• Statements around communication rated lowest by frontline and admin staff.

And from our further analysis….

• Delayed discharges of care (LA41) correlates with overall quality of relationships in the system;

• Where turnover and vacancy rates amongst staff (LA19) are high relational value is low;

• Lower than average relational value score is complemented by higher than average variation in scores within a system.

Local perspective…..

What different insight did the relational component of the LSR bring and how have you responded to your local findings?

So what?

• System pressures impact relationships and then performance

• Attention to relationship improvement will have opposite effect

Learning from deployment of the tool

• Intelligence gained;

• Exploratory approach - room for further development and improvement of both process and tool;

• Representative nature of findings – as most sites were ‘challenged’ findings cannot be considered representative. No sampling methodology was applied;

• Patient/carer/family perspective would add value.

Post LSR review

• LSR reports highlight areas for improvement, many of which are relationally focused;

• Suggest that CQC in collaboration with SCIE develop strategies centrally to address those findings that can be applied locally;

• Celebrate and recognize where relationships are identified as ‘good’;

• Use a ‘Relational tracker’ to keep relationships under review and monitor impact of improvement strategies.

Discuss…..

How could you use a relational approach as part of your improvement journey and what would help you prepare for this element of local

service review?