Karen Reeves discusses how an online toolkit that helps organisations decide if networked care is right for them is also relevant for commissioning specialised services
An ageing population, more treatable conditions, expensive drugs, increasing disease prevalence, and more high‑tech equipment mean that the NHS needs financially viable models of care to ensure sustainable services. Inconsistent quality in diagnosis and treatment, diagnostic duplication, unnecessary appointments, and poor clinical outcomes must be avoided.
The pressures facing acute hospitals, particularly smaller district general hospitals (DGHs), are often complex. These organisations find it increasingly difficult to afford delivery of safe and effective care across all clinical specialties and sub-specialties.
District general hospitals need to continue meeting their local population health needs while remaining financially viable. Patients want services to be provided at their local hospital rather than having to travel for care. Commissioners want safe, affordable services. Clinicians want to provide safe, high-quality services with good outcomes. This challenging context is unlikely to change.
Understandably, smaller clinical specialties are rarely a high strategic or operational priority for DGHs and often lack the benefits of scale in a local setting. In the absence of a critical mass of patient numbers or specialty workforce, care provision may become clinically or financially unsustainable. These difficulties are often compounded by competition generated by local commissioning arrangements and other providers.
As yet, there is no consensus about the best approach to delivering smaller clinical services in this context. The risk is that these services will either be subsumed by larger teaching hospitals or scattered across primary care, which will neither enhance the quality of local care nor support the sustainability of DGHs. Whole-system solutions need to be implemented to sustain smaller clinical services.
Whole-system solutions need to be implemented to sustain smaller clinical services.
New models of care
Moorfields Eye Hospital NHS Foundation Trust’s innovative approach to delivering care across multiple sites, which was initiated in 1994, has been referenced in various national policies on new models of care. In 2014, the NHS five year forward view1 proposed a model where a smaller local hospital might have some of its services on a site delivered by another specialised provider, citing Moorfields as an example. The model would help to sustain local hospital services and enable smaller hospitals to remain viable. The Dalton review2 published in 2014 categorised this approach as a contractual arrangement, which it described as a service-level chain. Often referred to as ‘the Moorfields@ model’, it is an example of franchising or networked care.
In 2015, Moorfields was selected by NHS England to develop an acute care collaboration (ACC) vanguard as part of the national new care models programme.3 These ACCs link hospitals together to improve their clinical and financial viability.
Single specialty networked care models, where one provider delivers services across multiple sites, enable clinical services to continue to be delivered locally, avoiding the need for patients to travel for care, and preventing local services becoming diluted or isolated resulting in lower standards and compromising care. They can also be embedded in large-scale transformation planning in hospital groups, mergers, and sustainability and transformation partnerships (STPs). Identifying where the expertise exists is of critical importance before exploring how best to share that expertise across a wider geography and developing the right partnerships to achieve this.
Many other NHS and commercial organisations deliver care across multiple sites, both in ophthalmology and other specialties, and have gained a wealth of collective experience. As part of the vanguard programme we asked colleagues dealing with these challenges day after day what it was like for them, what worked, and what did not, in the hope that their experience would help others trying to find the answers to difficult questions.
The Moorfields’ vanguard was, and is, an ongoing evaluation of the benefits and challenges of networked care and how a replicable, standardised approach to single service provision can benefit the wider NHS. The greatest challenge was that there was no clear picture of the final output. The process was iterative: it involved continuing learning and adjusting information gathering as ideas came together. The final challenge was codifying the extensive learning into one useful tool that would be relevant and usable for years to come.
The Networked care toolkit
The outcome of the Moorfields’ vanguard is an interactive, online toolkit for sustainable single specialty services.4 Launched in April 2017, it is free to access on registration, has 118 pages and 38 downloadable resources, 19 of which are usable templates. Any single specialty service can use the toolkit to evaluate if networked care is right for them and adapt its resources to fit local circumstances. It should be noted that the toolkit has been developed so that the principles can be applied to the development of any type of service across more than one site.
How to use the toolkit
The toolkit contains: best practice; evidence-based learning (EBL); and practical advice, guidance and frameworks. It is organised under four categories, each of which has three sub-categories. A short film available on the toolkit website helps users navigate the resource:
- Login or register at www.networkedcaretoolkit.org.uk4
- Select one of the four categories or do a search
- Access EBL, guidance, practical advice, tools, and resources.
The toolkit contains 10 steps to a networked care model, which helps organisations consider if networked care is right for them. It also includes a process to follow at each stage until the networked care model is ‘live’:
- Identify service concerns or other reason for review
- Agree a specialty review
- Plan the review visit
- Review visit methodology
- Review visit report and feedback meeting
- Develop a memorandum of understanding
- Develop the networked care solution
- Design the improved service
- Business case
- Mobilisation and transition.
Toolkit uptake and impact
Uptake is being measured through communications analyses. Since the toolkit was launched there has been a steady month-on-month growth in uptake (see Table 1). The impact of the toolkit on users is yet to be determined, but will help to quantify its value in terms of time saved, replication, and spread.
Table 1: Uptake of networked care toolkit, April–June 2017
|wdt_ID||Month||Number of registered users (demographic breakdown)||Number of website visits (new vs returning)||Number of video views||Number of documents downloaded|
|1||April||222 (64% NHS)||992 (665 vs 327)||743||1820|
|2||May||266 (63% NHS) +20% compared with April||365 (219 vs 146) –63% compared with April||841 +13% compared with April||129 –93% compared with April|
|3||June||298 (60% NHS) +12% compared with May||314 (164 vs 150) –14% compared with May||1066 +27% compared with May||191 +48% compared with May|
Moorfields@ model features and benefits
The overarching governance is an essential feature of the Moorfields@ model. Moorfields employs the staff across all 32 sites where it delivers care. Initially, several of its early networked sites were on a sub-contracted basis. Apart from one, however, they soon moved to the full-ownership model with directly commissioned services, which has given Moorfields the best provider accountability. At five of the sites, or partnerships, it provides clinical staff only and has no contractual relationship with the commissioners.
Different service delivery models and different partnership arrangements exist within the overarching governance arrangement. Moorfields provides complex eye services on DGH sites but more low-risk services in the community. With host DGHs it has both lease/licence arrangements for space occupancy and service‑level agreements that cover any mutual clinical support, such as anaesthetic cover and ward visits to the host trust. At smaller community hospitals and health centres there is a lease/licence arrangement with the landlord with no clinical service interdependency.
Box 1: Networked care toolkit categories and sub-categories4
Prelude: the development of the networked care model in the UK and overseas, detailed examination of Moorfields’ experience, and case studies on other models.
- Moorfields’ network history
- Moorfields’ network today
- Why single specialty networked care?
1. Purpose: why organisations might use networked care, the critical success factors, how to assure service quality and safety, and the potential benefits to the wider NHS.
- Quality and safety
2. People: how to work in partnership with patients and overcome challenges facing the NHS workforce:
3. Practicalities: guides, films, and tools to help organisations setting up networked care models:
- 10 steps to a networked care model
- IT considerations
Networked care providers operate a number of different models. The type of model adopted can be driven by circumstances: from a host trust needing clinical support to asking another organisation to take over the service. Best practice should inform the design of any network to ensure it delivers the best patient experience while meeting stakeholders’ needs.
Networked care sustains local services by the specialist provider delivering the service for neighbouring DGHs. At DGHs this has brought more specialist care locally and at community sites low-risk services are now delivered locally, saving patients travel time. Staff are part of a consistently led single specialty network with the support and wider development opportunities this brings. Better learning is achieved across a wider cohort of patients and staff from incident reporting and shared learning through improved quality and safety. Specialist care delivered locally brings improved clinical outcomes and the opportunity for standardisation, which is critical for reducing unwarranted variation and waste of resources.
Best practice in networked care
Networked care works. The rationale for the Moorfields’ model of ‘owning’ the network has developed through over 20 years’ experience. From shared learning with other networked care providers, the critical success factors for best practice in a networked care model can be identified (see Box 2).
While the focus is on sustaining local services, providers who are best positioned to support these smaller services need to be incentivised. A well‑performing service provider is unlikely to want to take on the problems of another hospital that needs investment in staff and equipment. The type of model adopted will have to take account of all these issues. The Moorfields’ ‘ownership’ or ‘franchise’ model gives the specialty provider scope to plan a business model that improves patient experience, delivers longer-term sustainability, and provides a contribution back to the specialty provider trust; or to make an assessment that these conditions cannot be met.
Box 2: Critical success factors for best practice in a networked care model
- Excellent staff who are able to work well at a distance but know when to escalate
- Organisational buy-in—a clear strategy on the purpose of the network is required and may need to change as the network evolves
- Professional buy-in—do consultants believe in the network model and do they support each individual venture?
- Choice of partner—be clear on the terms of the relationship and align understanding of what a successful partnership will look like
- An understanding of the health needs of the population the network is seeking to serve and the expectations of those who commission/purchase care
- The importance of reputation and protecting the brand
- A well thought-out management structure with clear lines of responsibility, communication, reporting, and escalation
- Standardised processes with tightly controlled variation to ensure consistent quality
- Excellent links between sites and the centre to spread learning
- A central learning and development team that moves between sites
- A values-based culture, embodied by strong leadership
- Clear agreements with host sites
- Excellent remote connections and systems.
The new care models programme aims to promote standardisation and replicability across the NHS. After staffing, standardisation is essential to reduce unwarranted variation and improve quality and safety. However, although standardisation is the key to delivering high-quality care, it is not always easy to achieve.
Neither national nor international geography should be a barrier to standardised governance frameworks. Flexibility for local innovation can be built into standardised models; the need to adapt to local conditions should not be a reason not to adopt a standardised approach.
In any well-governed organisation, everyone needs to know what they are supposed to be doing and how they are supposed to do it. Some variation is necessary to enable individual sites to respond promptly to local conditions; how much variation is acceptable must be established. A robust clinical governance framework with standardised guidelines, policies, and protocols across all sites is essential if care, surgery, and outcomes are to be consistent.
Networked care offers standardisation a platform on which to grow across a health system. The Moorfields’ care model suggests this is best achieved by a provider with the specialist knowledge to take on the challenge of networking to other provider units. The form this network takes is for local agreement and it will have to take account of local commissioning arrangements.
In year two of the vanguard programme, Moorfields is considering the benefits and challenges for stretching the model geographically or numerically across STP boundaries and assessing the implications for commissioning and regulating the model.
The vanguard programme is also learning from, and trying to replicate, the process used by the National Orthopaedic Alliance (NOA) ACC vanguard,5 which brings together orthopaedic units across England in a membership model. It builds on the Getting it Right First Time (GIRFT) programme to provide a national framework for improving quality in orthopaedic care.6 Clinicians and managers from member units work together to agree standards and recommendations based on: high-quality, relevant evidence from comprehensive literature reviews; published national guidance by, for example, the National Institute for Health and Care Excellence (NICE) and applicable professional bodies; GIRFT data and similar; together with expert consensus.
Ophthalmology is the first area for replication, supported by the NOA and the Moorfields vanguard programmes, the ophthalmology clinical reference group, the ophthalmology GIRFT leads, and the Royal College of Ophthalmologists. Ophthalmology providers and other organisations are working together nationally to agree quality standards, best practice pathways, and service specifications; supported by informed evidence allowing benchmarking of processes and outcomes to improve standards.
Key trusts that provide ophthalmology services were invited to consider the proposal, along with other stakeholders, and potentially become founder members of an ophthalmology alliance. This is an exciting project that will see ophthalmology providers improving standardisation and best practice.
The UK Ophthalmology Alliance has now been established and will help smaller services to better understand if they can achieve these standards to remain sustainable and help providers across a system to align services and benchmark with each other.
If replication is successful more services will be encouraged to adopt this model.
Assuming the standardisation agenda is being addressed, the other significant challenges are the part that financial constraints, critical mass, and workforce models will play in deciding where, and when, high-quality services can be networked safely. This is in addition to the contribution they can make to the local and national commissioning agendas.
It is clear that sustainable solutions will depend on local conditions, and there are many different ways to deliver networked care. The strength of the networked care model is standardisation across clinical and corporate governance—from resource management to strong local clinical leadership.
As a learning resource, the Moorfields’ online toolkit has relevance for any single specialty service whether smaller hospital, specialist provider, or commissioner. The 10 steps to networked care process and templates provide a practical way in which services can be evaluated, and can be used strategically and operationally. The toolkit content and other resources will help with the analysis of the benefits and challenges in any given service scenario.
As accountable care systems develop, networked care is an option for managing smaller service specialties across the health economy to standardise provision, avoid unwarranted variation, reduce duplication, and offer financial sustainability. Clinical networks will go some way to achieving these outcomes, but networked care may offer additional benefits such as: improved access to local services that may not otherwise be sustainable; a greater range of sub-specialties; improved equity of access to services; better fit with the local commissioning landscape; and improved careers and opportunities. For patients, it can offer best in class delivered locally.
- NHS England. NHS five year forward view. Redditch: NHS England, 2014. Available at: www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
- Department of Health. Examining new options and opportunities for providers of NHS care: the Dalton review. London: DH, 2014. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/384126/Dalton_Review.pdf
- NHS England website. Vanguards. www.england.nhs.uk/ourwork/new-care-models/vanguards (accessed 27 October 2017).
- Moorfields Vanguard Programme Team. Networked care toolkit. London: Moorfields Eye Hospital NHS Foundation Trust, 2017. Available at: www.networkedcaretoolkit.org.uk
- NHS England. National Orthopaedic Alliance. www.england.nhs.uk/ourwork/new-care-models/vanguards/care-models/acute-care-collaboration/noa (accessed 27 October 2017).
- Getting it right first time website. gettingitrightfirsttime.co.uk (accessed 27 October 2017).