Don Berwick

I have recently returned from an exciting, whirlwind tour of another set of new care models sites. This was my fourth such tour. My goal for these visits, which I make as an International Visiting Fellow for The King’s Fund, is to attempt to understand what the vanguard organisations are trying to do, how well they are faring, and how they might progress even better and faster. On this trip, the additional question was: ‘How can these lessons and models be spread more widely across the NHS?’

Let me recount a few of the many highlights, and then summarise some general conclusions about the new care models investment.

My trip began in Better Care Together (Morecambe Bay Health Community), but not at a health care facility. Instead, I found myself at the Westgate Primary School, being escorted by a committee of six 10-year-old children. They explained to me that they were participants in the school’s programme to encourage pupils to run one mile every day – six laps around the school yard – in almost any weather. The teachers ran too. The children reported increased alertness, better sleep patterns, and having fun. Every single child at Westgate Primary does the same, every day.

The programme had been brought to the school by a Morecambe Bay GP, Dr Andy Knox, who – with the support of his clinical commissioning group (CCG) – is devoting two days a week to helping improve health and wellbeing in schools. He has adapted the ‘Daily Mile’ programme used by St Ninian’s Primary School in Sterling, Scotland, which has just about eliminated obesity in its lower primary grades. As of now, 2,000 children in Morecambe Bay are running a mile a day, and 3,000 more from around Lancashire will be doing the same within the year. The likely result: massive reductions in diabetes and other complications of being overweight within this generation. Dr Knox is setting his sights on family and school nutrition next.

A few miles away at Lancaster Royal Infirmary, GP Dr George Dingle introduced me to the ‘Advice and Guidance’ programme. With the full support of the hospital’s chief executive, Jackie Daniel, and the local GP community, this is linking more than 300 GPs and consultants across 17 specialties in a rapid, internet-based review of patients who could be referred. This has resulted in a decrease in actual referrals by more than 30 per cent, with more satisfaction for GPs, consultants and patients. More than 4,500 such consultations occurred in the past 12 months.

A trip to Leeds followed, and a meeting with six vanguards to hear about the work from Wellbeing Erewash, where GP Dr Duncan Gooch and CCG head Rakesh Marwaha are pioneering a new ‘GP-lite’ primary care model focused on patient-led goals, home-based care, multidisciplinary teamwork with community organisations, and anticipatory interventions – all aimed at keeping people in their homes and functioning at their best possible level. They are engaging all 12 GP practices – more than 60 GPs – in Erewash, and are beginning to teach clinicians in other Derbyshire sites about their new model.

Two care home vanguards – Connecting Care – Wakefield District and Sutton Homes of Care – were also on my itinerary, and I saw first-hand extraordinary degrees of co-operation among staff in care homes, GP practices, hospitals, community nursing, and ambulance services to assure that residents’ problems were intercepted long before hospitalisation was needed, and that hospital stays were as short as possible. Sutton is using the ‘Red Bag’ innovation – a pre-packaged collection of supplies and records that accompany every patient to hospital. The Red Bag pathway appears to have reduced average hospital length of stay by four days. More than 98 care homes in Wakefield and 80 care homes in Sutton are engaged in these programmes of work.

I could go on. One site after another with energised clinicians, managers and staff, creating and testing new ways to achieve better care, better health, and lower cost through improvement – with a sense of buoyancy and pride frankly at a low ebb in much of the NHS at this stressful time. And the grassroots leadership by GPs, nurses, frontline managers and others is palpable. The NHS five year forward view presents a top-down vision, and this is real bottom-up movement towards that vision.

In my view, the new care models investment is paying off in results; not everywhere and largely still in local settings, but well enough to offer hope that redesign and improvement can offer the NHS a route to an entirely new level of performance.

To achieve that, the next (and essential) step must be to ‘spread’ and ‘scale-up’ these initiatives, not just in the vanguards but across the NHS. I put these terms in inverted commas because ‘spread’ and ‘scale-up’ are not linear. They cannot be mandated, installed, or ordered up. For complex changes in complex systems, adopting someone else’s innovations is not like plugging in a toaster; rather it is like learning to speak Spanish or play a piano. Experts, pioneers, coaches – they can all help, but the successes of Morecambe Bay, Erewash, Wakefield and Sutton will need to be studied, adapted, tried out and refined site by site, with local leaders just like Andy Knox and Duncan Gooch carrying the flag. That will take time, encouragement, and tolerance for the awkward phases of learning.

I can see the potential pay-off: massive. The challenge and the discipline for the senior ranks of the NHS and the government will be to trust the people of the NHS, give them the tools for learning, and offer the time and space to draw the lessons they can from the pioneering vanguard sites.

• Catch up with Don Berwick’s recent live online event on quality improvement
• Improving quality in the English NHS