David Fillingham CBE is Chief Executive of the Advancing Quality Alliance (AQuA). He is also co-author of a forthcoming joint report from AQuA and the Health Foundation on the challenge and potential of whole system flow in the health and social care sector. Here David tells us why he thinks a focus on improving flow could offer solutions for some of the major challenges currently facing the NHS.

What does whole system flow within health care mean?

Anyone who’s been a patient, or had an elderly relative go through the health care system, will know what a lack of flow looks like: frustrating delays and wasted resources. Sometimes patients and families can feel like they are the only people pulling the different parts of the system together. That absence of a smooth effective flow of patients, information, resources and staff has big knock on implications for patient experience, but also for safety, outcomes, and productivity.

There have been many attempts to improve flow, but projects have tended to focus on only one part of the system and usually on hospitals, particularly emergency departments. When we talk about ‘whole system flow’ we mean something broader. We need to start looking at what’s going on in other parts of the health and social care system, and to improve things using all the resources in a community. It’s a much bigger challenge.

How can focusing on whole system flow help with improving care quality and reducing costs?

At the moment people in England are busy working on their Sustainability and Transformation Plans (STPs) and developing new models of care. But none of this will deliver results unless we find a way to move patients and resources around the system in a more effective way. I feel really strongly that tackling whole system flow provides the underlying principles for developing new models of care more effectively.

There are three huge benefits to improving flow:

  1. Patients get a better experience and outcome. If an older person with a number of long-term conditions can’t get to see their GP, they may deteriorate and need to be taken to A&E. Before you know it they’ve spent hours waiting to be admitted, and then they’re in hospital weeks or months longer than necessary because they can’t get discharged. That’s a very poor experience.
  2. High-quality care is delivered using fewer resources. Had we got the right intervention in place at home much earlier for that person they would never have been in hospital in the first place. This is often called failure demand, which represents a big part of the pressures on our services, as we explore in the report (to be launched soon).
  3. Better flow leads to happier staff. Patients aren’t the only ones who feel frustrated by bits of the system not joining up properly, it really impacts on staff as well.

How does change happen in complex systems and how can improving flow help?

We’ve found there are a number of quite hard-edged things we need to do to get systems to work together effectively, including developing supportive financial incentives, information systems and service design. But there are also ‘softer’ things around leadership, culture and relationships which are absolutely crucial.

Some of the Health Foundation’s work through their Flow Cost Quality programme in Sheffield really helped us learn about how you can engage frontline staff in improving flow, and they got some great results.

The Wigan Deal is also particularly interesting. Wigan Council led a programme to reform care and wellbeing services. Appreciating that they were dealing with a complex system, they invested in training large numbers of staff in the principles of the deal, giving them permission to think differently and work in a different way with local residents. They’ve now developed a number of new care and support packages in the community that are more person-centred, much less expensive, and better meet residents’ needs. This has helped them identify over £8m in permanent revenue savings so far.

Wigan has now created an integrated care partnership organisation, bringing health and social care providers together. It’s definitely an area to watch.

The NHS in Scotland and Wales are also looking at improving whole system flow so it’s been great to work with colleagues from across the border on this. Find out more in our forthcoming report which will include case studies on their work as well as examples from further afield. 

Where should people start if they want to improve whole system flow?

People often just think about the patient journey. This is the right place to start, but on its own it doesn’t show a full picture. You also need to think about how the people working in each of the services along that patient journey will be equipped with the skills and support to bring about improvements. And if you want to have a wide and sustained impact you have to work at system level too. That’s about engaging senior leaders, so they understand how parts of the system need to work together and can tackle the big barriers they have the power to influence.

In our report we will set out a model for whole system flow, which shows that we need to be taking action on four different levels: patient, frontline team, local health and social care economy, and the national system.

Is current national policy supportive of improved whole system flow?

In England, we’re seeing a very healthy direction of travel on this through things like the sustainability and transformation planning framework, and the new single oversight framework from NHS Improvement and CQC. It’s all encouraging a more integrated system.

I have two big worries though. Firstly, the basic funding shortfall in the NHS, which is enormous. People are spending so much time firefighting. The second thing is social care funding, because while there is a squeeze on the NHS, it’s been much tighter for longer on local authorities. Social care can’t play their part if the money just isn’t there.

This sort of whole system transformation takes time. Is there enough patience around for this kind of approach, bearing in mind the NHS’s current financial situation and other big challenges?

Changing senior leadership is often seen as the solution in places with large deficits and big performance problems. That makes whole system transformation hard as it disrupts relationships within the local community and new leaders will naturally focus on quick fixes.

However, I am a relentless optimist. Places like Wigan, that have been allowed to build a constancy of purpose and consistency of leadership over a longer period of time, are really starting to prove that agencies can work together effectively with impactful results. Their results show that a two year timescale is long enough to start to demonstrate initial results. What we need to do is drive that forward, and help people demonstrate their success. This will then become a model for work in other parts of the health and social care system. 

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