Introduction

Latest UK policy upholds the need to involve clinicians and patients in commissioning/planning decisions.   The government's response to the Future Forum calls for  widening clinical input to commissioning by establishing advisory clinical senates and clinical networks.  In  English policy it was first recognised in Our NHS, Our Future and  World Class commissioning (WCC) , which required commissioners to:

• Lead continuous and meaningful engagement with clinicians to inform strategy, and drive quality, service design and resource utilisation (Competence 4)
• Promote and specify continuous improvements in quality and outcomes through clinical and 
  provider innovation and configuration(Competence 8)
• Proactively seek and build continuous meaningful engagement with the public and patients, to 
  shape services and improve health (Competence 3).
   

IMPRESS position

At the time of World Class Commissioning we strongly advised that the local health economy set up, or expanded, existing networks/planning and  strategy groups to ensure that there is representation of service users and carers, public health, smoking cessation and exercise experts, primary and secondary care clinicians (doctors, nurses and allied professionals), practice based commissioners, PCO commissioners, social care, and other parties who have expertise and local knowledge to contribute.  There are useful resources from NHS Networks about running networks http://www.networks.nhs.uk/network-resources and from  National Prescribing Centre http://www.npc.nhs.uk/personal_org_dev/working_others/resources_groups/quiz_buildingnetworks.swf

Since then many of the regional clinical leadership teams have supported the creation of networks at regional and local level,  with the aim of meeting, sharing experience and starting to review data to trigger discussions about improvement.

Lessons from IMPRESS as a network role model

1. Involve:

• Project/programme manager - argue for dedicated project management time
• Managers, commissioners, healthcare professionals
• Primary and  secondary care and community providers
• Lay representation and ways to involve patients
• Social care
• Third sector providers where appropriate. Need to develop a position on this.

2. In addition to email and teleconference, communicate face-to-face because it achieves:

• Increased respect across boundaries
• Shared beliefs

3. Share resources, knowledge, opinion eg primary care innovation

• Learning: gain from different attitudes eg to risk
• Positive relationship with pharma industry (check PCT view but national policy is supportive)
• Primary care : find ways to demonstrate competence
• Secondary care: consider  responsiveness
• Campaign for investment in respiratory care: demonstrate how it can meet commissioners’ aims:
  • improved supported self management
  • reduction in avoidable hospital readmissions and admissions
  • care closer to patients’ homes
  • prevention (“upstream” eg system-wide leadership for smoking cessation)
     

4. Use networks to  horizon scan

Evidence

The evidence about networks suggests that the inclusion of “boundary spanners” and a network manager is also vital to its success. We suggest its role should be to agree on an assessment of local need, undertake a gap analysis using pathway mapping or other improvement tools describe a vision for local services and set standards.  In Scotland, where Managed Clinical Networks are an essential part of policy implementation, one of the key roles is overseeing the training and education requirements of local clinicians, audit, and monitoring service provision.  In Scotland this role has come out of the findings of the needs assessment process that typically highlights a lack of knowledge amongst clinicians in primary care.

Example of a multi-disciplinary network focused on value/QIPP that has been in operation for several years:
From our guide How to Prepare a Service Specification: use of a network for implementing NICE guidance Source: Dr Steve Connellan.

"A NICE implementation group  sat monthly and comprised GPs/consultants/finance/audit/IT/pharmacy reps and was chaired by the acute trust and PCT alternately. This considered all issues to do with horizon scanning, recently published guidance, Payment by Results, and financial implications for the whole health economy rather than 'them and us'.

Whenever a new guidance was published, a grid of recommendations was produced and this happened for COPD and  TB. All stakeholders were then given the opportunity to respond to the guide and the collated response distributed so that everyone could see any hurdles to NICE implementation and (usually) any financial restrictions. There were timeframes for completion of these parts of the process and a database produced that could be accessed by both primary and secondary care. With regard to COPD, we were able to proceed with appointment of a GPwSI (with session for Consultant Respiratory Physician and training resource), establishment of a resource centre, community pulmonary rehabilitation and stronger links between our Consultant Respiratory Nurse and the PCT. There were inevitable frustrations regarding timeframes, finance, attendance and it certainly wasn't all 'rosy' but the model was at least one way, based on NICE, to have a structured dialogue which required a response, whether negative or positive."

What is the network’s role in service delivery?

The network may also have a role in service delivery.  In the Scottish system, the network acts as an advocate, plugging into existing systems for provision and commissioning and offering /expert advice and facilitating change.  In England, networks are less formally developed.  However, the more successful the trust and relationships are between the network, the more likely it is that the commissioner would look to the network to advise on the service and to find ways to improve it.  We await the outcome of the debate on the Health and Social Care Bill to know how networks, integration and competition will be balanced.

If a new service is required, with significant investment, then commissioners are likely to be bound by European Union rules on procurement, and they will have to decide how best to do that. 

  Some of these points are drawn out in a recent Health Services Management Centre paper Integrating Care and Transforming Community Services: What Works? Where Next? 2009.

NIHR SDO study on networks in health care

An NHS SDO research project has  been published by  Ewan Ferlie: Networks in health care: a comparative study of their management impact & performance click here  to download an Executive Summary and full report.  It asks the question "Should health care be organised through markets, hierarchies or networks?"  It has used cancer  networks as one of the study subjects, and has some interesting findings that IMPRESS would support from its experience as a network.  Firstly, it points to existing evidence that "trust building is central to the functioning of networks" and that networks have emerged as the most logical way to support people with chronic disease that need to link health and social care and primary and secondary care across organisational and professional boundaries.  It also highlights the role of networks in improvement programmes as a "governance mode able to diffuse good practice and rapid learning".It then highlights from its findings:

• Potential to use ICT more.  IMPRESS uses email and teleconferences punctuated by quarterly face-to-face meetings and is exploring other technologies for sharing knowledge. The NHS Institute is using Webex, and so the ICT technology already exists
• Disappointing organisational learning in networks despite their potential for this. As a national network intent on providing clinical leadership, IMPRESS h as paid attention to this, as a core function.     The evidence suggests that learning depends on "absorptive capacity" to bring in new knowledge from outside and turn it  into something  useful. It also depends on effective boundary spanning  and specialisms (eg primary and secondary care) need overlapping or redundant knowledge to support knowledge sharing (referenced work by Quintas)
• Government policy/institutionalisation of evidence-based guidelines and national frameworks supports networks to bring about improvement - we know that  NHS Improvement  advocates networks and communities of practice as models to support the implementation of the  National Outcomes Strategy for COPD and asthma in England.
• Boundaries can exist between different communities of practice.  The report highlights epistemic community of practice - that is, one that shares a mindset or who accept one version of a story, or one version of validating a story.  IMPRESS members, crossing primary, secondary and community care; management, commissioning and service delivery, has definitely developed a shared mindset. It has to work to ensure that the potential boundaries between it and its founding organisations, whose members may have different mindsets, are acknowledged and spanned.
• Need well developed leadership and management capability. IMPRESS would endorse this.
• In addition to networks, there's value in creating  small mixed teams, boundary spanners and "clinical managerial hybrids", resources. and shared processes. IMPRESS supports all these findings through its own experience.
  
  
• Advantages of networks
  Dealing with complex cross-boundary issues 
  Potential as implementation networks
  Secure high level clinical engagement, especially if backed up by clinical guideines
• Disadvantages of networks
  Can be a talking shop
  Could be closed to outsiders
  May have weak focus
  Without an "office" they drift 

Further resources

IMPRESS is in regular contact with the NHS  Improvement -  Lung launched by NHS Improvement to support the development of clinical networks and the implementation of the  National Outcomes Strategy for COPD and asthma.  Its  team  support respiratory leads in the regions, the development of Respiratory Networks, and pilot programmes to improve the management of respiratory disease. It will build on the successes of existing national improvement programmes in Cancer, Cardiac, Diagnostics and Stroke services. The Programme aims to support clinical teams, commissioners, service managers and other key stakeholders deliver effective clinical practice through process improvement and redesign. Click here.

IMPRESS will continue to work with the programme to share examples of good practice, and to support the development of local networks.

Presentation at IMPRESS inaugural conference from Dr Iain Small

Cancer networks: http://www.cancerimprovement.nhs.uk/

Royal College of Paediatrics and Child Health: A Guide to Understanding Pathways and Implementing Networks - December 2006 
It includes a guide to setting up networks. See here.

Scottish Managed clinical networks
http://www.nhshealthquality.org/

http://www.networks.nhs.uk/network-resources
NHS NEtworks has links to all guidance papers and checklists on networks from Scotland and England. Neil Goodwin papers are good.

Nigel Edwards paper 2002 BMJ on PubMed
BMJ. 2002 January 12; 324(7329): 63 
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1122027