Dorset’s journey to becoming an accountable care system

11th September 2017

Dorset’s journey to become an accountable care system (ACS) involved a three-year programme of work. This included a new focus on co-design, open and honest dialogue, some difficult conversations and the cultivation of strong relationships between partners old and new.

This cannot be done quickly and there are no short cuts – especially where clinicians who care deeply about creating the best outcomes for patients are concerned. Combine this with navigating the complex assurance process needed for success and it can be a long process.

In the first few months after Dorset Clinical Commissioning Group’s establishment, we realised that there was an impending and urgent need to review clinical services within the county. In common with much of the rest of the country we faced huge pressures, so we began to define the case for change.

This centred on an ageing population, rising numbers of people with long-term conditions, escalating workforce pressures across primary and secondary care, a variation in quality of care and outcomes for people, and the impending and growing financial crisis. These were the compelling drivers for change.

Our Clinical Services Review was launched in October 2014. Initially focussing on acute reconfiguration, the CCG led a series of clinical working groups initially monthly over a period of six months, and later extending to 13 in total as we encompassed community care.

More than 600 primary, secondary and community care clinicians came together and after each group there was a period of reflection, review and opportunity for further input to the discussions before moving to the next meeting.

We discussed our aspirations for a better health care and system, bringing forward national and international examples of good practice, and together we created a vision of ‘what good looks like’.

This was a fast paced piece of work. The work streams were divided broadly into clinical areas and through the months we worked together to paint a picture of the model of care for Dorset.

Essentially, this way of working provided the right forum for discussion, debate – sometimes disagreement – but importantly relationship – building across the system.

A consensus formed for a model of acute care with one major emergency hospital focusing on 24-hour consultant delivered care in line with the Keogh Review principles, and one major planned care hospital sitting in the east of the county. Alongside these, a hybrid major and planned hospital would sit in the west of the county, taking account of its distinctive rurality.

Considering a long list of site-specific options and reducing them to a short list gave us options to further evaluate based on a series of criteria that had been established in advance.

Reference groups were established – clinical, finance, estates, patient, workforce – to work through the implications of the changes planned.

Recognising that the focus could not solely be on acute hospitals and that the out of hospital model of care was critical to the success of the system meant that very quickly we moved to a review of community services. This included the model for integrated community care and options to redesign services in each of our 13 community hospitals.

There was an increasing focus on sustainability and transformation of primary care as the bed-rock of community care. Acute mental health pathway redesign ran in parallel.

Working alongside local authority partners more closely for the first time brought a whole new set of relationships and a focus on whole system solutions including prevention.

There were many challenges around organisational alliances and resistance to change. The sheer scale and complexity of this cannot be underestimated and consistent leadership behaviours need to be maintained always.

What started as a piece of work around the acute sector rapidly and rightly became a whole system review, and consultation on the potential shape of the Dorset healthcare system has now been completed.

The NHS has historically evolved little by little, with services growing piecemeal without thought to the wider system.

While seemingly obvious, review at this scale rarely happens. Strategically it is absolutely the right thing to do but cannot happen without honest engagement of clinicians, patients and managers who have come together to share a common vision based on a strong case for change.

The need for excellent, even relentless, communication and engagement is paramount and cannot be underestimated.

Building trust between new partners, identifying key stakeholders to act as agents for change within their organisations and supporting these new leaders is critical for success on this difficult but worthwhile journey.