“Going beyond what individuals and teams can achieve for a greater combined impact”: exploring SCIE’s webinar on system thinking

Last week, the Social Care Institute for Excellence (SCIE) conducted their most recent webinar entitled ‘System thinking and culture change through clinical care and professional leadership’, as part of NHS England’s ongoing series focusing on integrated care systems.

The latest episode focused on exploring professional identity and the challenges and opportunities for multi-disciplinary leadership, which featured an panel of speakers from various backgrounds, including Professor Sir Chris Ham, (co-chair of the NHS Assembly); Dr Fiona Chatten (primary care development lead, North East and North Cumbria Integrated Care Board); and Kerryjit Kaur (head of integration and transformation, Leicester, Leicestershire and Rutland Integrated Care Board).

Here, we will share some of the key points raised in the webinar.

What is global thinking?

As part of the webinar, Professor Chris Ham gave a presentation on global thinking, examining the function of integrated care systems on a universal scale. Noting the importance of looking at the bigger picture, he said: “Why are we talking about these issues around health and care systems today? It’s really because of the demographic changes, and also the changes in the burden of disease within our population. We know we have a growing population in this country but also an ageing population. Many people age well but some do not and there’s the challenge of increasing frailty, which is a big part of the workload of health and care professionals. With a disease burden, there’s some good news and bad news.

“The good news is that around the world, if you look at the global burden of disease study, we’re achieving more and more success at preventing premature deaths from cardiovascular disease (CVD), from cancer and other major causes. 

“The bad news is that although people are living longer, it is not always in good health. There are particular challenges around chronic medical conditions. Multi-morbidity is one example of that huge workload. The third challenge is risk factors; behaviours which will build up challenges for us in the future, such as cigarette smoking, misuse of alcohol, the food we consume, physical inactivity and so on. If we are not effective in addressing these factors, the consequences for future diseases and conditions will be considerable and perhaps even unsustainable.”

Chris continued: “Secondly, it’s important to note that it is not possible for individual health and care professionals or organisations to successfully respond. We need to combine all of our assets, all of our expertise – firstly in joining up care, integrating care around people who have complex needs but going beyond that.

“For me the big prize is where we get into the field of prevention – joining up all assets and expertise in relation to population health and population wellbeing. We need to work in systems, going beyond what individuals and teams can achieve for a greater combined impact.”

Chris shared an example of such work in New Zealand, noting that GPs in Christchurch have come together with hospital-based specialists and respective teams to develop ‘health pathways’. “For patients with type 2 diabetes for example, they look at how they are currently accessing support and examine how they should access that support in future by adopting best practice guidelines, and also drawing on the experience of the people who are working within the area,” Chris explained. “Those health pathways have made a huge difference to the experience of care and outcomes of care within that particular system. This is something we can learn from and adapt to our own environments.”

Similarly, here in the UK, Chris noted that a population health approach has been adopted in Wigan. He described how the “voluntary and community sectors work with the local authority, with the NHS organisations and others, to understand the needs of the population. They are identifying people and communities most at risk and bringing together the contribution of the different public services by investing more in voluntary and community sector organisations.”

“We need to be humble in recognising that we don’t always have the answers. Many of those answers can be found in innovative voluntary organisations that understand their population and communities.”

Professor Chris Ham

Chris acknowledged: “Particularly for those of us working in the public sector, we need to be humble in recognising that we don’t always have all the answers. Many of those answers can be found outside in innovative voluntary organisations, large and small, that understand their population and communities. Often they have found different cost-effective ways of identifying and then responding to the needs of those people.”

One of the most important points is that of relational issues, he said; looking at the changes in behaviour that we need to see in order to create multidisciplinary teams at micro-system level, and ensuring that agencies are committed to developing and implementing a shared vision in order to improve outcomes for the population. “How do we leave behind the old competitive behaviours and introduce partnership working and collaboration?”

On professional identity

Dr Fiona Chatten then explored the role and significance of professional identity within an integrated care system.

“I was given the opportunity to undertake a PHD in integrated care and I was really fascinated by how people felt about themselves within their own profession, particularly when we ask them to work in a different or integrated way,” Fiona said. “I was watching some of my ex-colleagues being moved into new integrated teams and I was interested in asking how they felt about themselves within their own profession. I discovered that we have a tremendous amount of research and understanding about all the different types of integration and also professional identity. 

“However, we have very little knowledge about the intersection between the two, and actually it’s incredibly important. It’s how we define and categorise ourselves in our work role in a professional context. For example, I refer to myself as a nurse; we gain that sense of identity really early on in our careers and this creates a sense of belonging and supports psychological safety and self-esteem. It gives us a feeling of familiarity and security. We need to socialise with our peers within our profession, both to form that identity, but also to maintain that identity throughout our careers.”

When we ask people to work across systems or move into integrated teams, Fiona said, “This brings an element of risk because to some extent we will be impacting that social connection and maintenance of identity. Often people feel threatened by integration. Sometimes it’s too much change. There’s also something about professional individuality and people feeling as though their roles are getting eroded.”

Fiona highlighted a term from her research called ‘creeping genericism’ in reference to this sensation of roles getting eroded. “They feel they are losing that unique element their role brings, which is something we need to be aware of – because that can result in defensiveness and a need to protect their profession,” Fiona explained. “If I feel like my profession is being changed too much or I’m losing that individual aspect, I will feel defensive and I’m going to be resistant to integration.”

“Making people feel safe and secure will make staff stay within teams… it’s at this point that we get the best patient care.”

Dr Fiona Chatten

‘Positive professional identity’, meanwhile, refers to a person who feels secure in their role and professional identity. “They have that psychological safety and they feel understood. It’s at this point that we get the best patient care and I would say we get the best retention of staff as well. Making people feel safe and secure will make staff stay within teams. It’s about making people feel truly valued, understood and recognised.”

On how the health and care system can support this going forwards, Fiona said: “We need to enable support, encourage and facilitate opportunities for professional groups to support each other within their own profession, and promote team activities to nurture a new multi-professional identity.”

Multidisciplinary working in practice

Kerryjit Kaur shared an example of multidisciplinary working in practice, through Leicester, Leicestershire and Rutland’s (LLR) new unscheduled care coordination hub (UCCH).

“The need for this service emerged from a number of our patients at LLR waiting in the back of ambulances outside our acute hospitals, unable to receive the care they needed quickly,” Kerryjit explained. “We wanted to improve that. The UCCH is a one-stop-shop and acts as a single point of contact for referrals coming into the hub itself.”

Kerryjit described how LLR sought to improve on fragmented care pathways by working together with local health and social care services in the UCCH, to take responsibility for managing the needs of sub-acute patients.

“The UCCH provides real time access to a senior clinician, who can take clinical responsibility for a patient from the East Midlands Ambulance Service (EMAS) or another health care provider,” she said. “Initially we looked at how we could support EMAS colleagues – how do we monitor their activity? We knew that a number of the cases coming into our hospitals could be supported by local community care, voluntary sector and so on. We decided to look at a hub model where we could integrate organisations already working to support people. We started to ask them what a good model of care would look like and how could we improve their working day.”

Kerryjit continued: “These were individuals within teams that hadn’t worked with each other previously in a face-to-face environment. We needed to look at what these roles actually meant to people, what their responsibilities are, what their accountability looks like – but also what does the shared risk look like? Do we have an ethos or vision in place ensuring that we share that risk appetite? It can’t just be one organisation holding the responsibility; it’s a number of organisations working together, and it’s a team effort driving the model.”

Kerryjit described how LLR sought to change the approach within the model to a ‘no wrong door’ approach, to ensure that they could always match people to the appropriate care pathways and treatments. Even if the UCCH could not help at a particular time, the aim was to be able to proactively signpost the patient to another service within the system so that the answer wasn’t ‘no’. The team would look for ways to support the patient at that moment in time even if the UCCH was not the answer.

“The aims of the UCCH involve utilising a multidisciplinary team who decide how best to respond in order to meet the patients’ needs, based on the clinical requirement and urgency agreed with the referring clinician,” Kerryjit summarised. “The hub provides the ability to interact with crews on the scene to provide viable alternatives to attending hospital. Pathways should include access to same-day community unscheduled care, virtual words, community mental health, urgent treatment centres, frailty services and more.

“This has really changed the way people see a single point of access and has allowed people to share their skills. It allows them to ask, ‘what could we bring to the table, and how can we support other services to do the same?””

It is a grass-roots approach, Kerryjit pointed out, based on what LLR know from previous experiences and also based on what practitioners tell the team on a daily basis. “It’s important to remember throughout the process that no models of care are perfect; something has to go wrong for us to look at what needs to change. You have to give yourself permission to make mistakes. It’s about knowing that we will make improvements at every step of that journey and continue to learn from each other as we’re doing that.”

To view the full webinar, please click here.