Networks

Introduction
The need to involve clinicians and patients is borne out in World Class commissioning (WCC) and in
the process demonstrated in the Our NHS, Our Future review. WCC requires 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

We strongly advise that the local health economy sets up, or expands, 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_support and from NHS Evidence. http://www.evidence.nhs.uk/Search.aspx?t=networks

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.

It may be possible to build on the review group work that contributed to the Our NHS, Our Future as the starting point.

Example
From our guide How to Prepare a Service Specification: use of a network for implementing NICE guidance Source: Dr Steve Connellan.

"We had a NICE implementation group which sat monthly and comprised consultants/GPs/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 more recently 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.

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. See IMPRESS procurement page.

We expect that the forthcoming National Strategy for COPD in England will support the development of networks at regional level. We also recognise that networks can improve care coordination but some policies, such as the policy on competition, may create barriers to integration. 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.

NEW EVIDENCE MARCH 2010
A new NHS SDO research project has just been published by 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 attaention 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 the Lung Improvement Programme is exploring networks and communities of practice as models to support the implementation of the new National Strategy for COPD 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

Lessons from IMPRESS as a network role model

1. Involve:

Project 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? 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

Further resources

IMPRESS is in regular contact with the NHS Lung Improvement Programme launched by NHS Improvement to support the development of clinical networks and the implementation of the forthcoming National Strategy for COPD. Its Lung Improvement team will support respiratory leads in the SHAs, 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 Lung Improvement 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 work with LIP 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.
http://www.rcpch.ac.uk/publications/recent_publications/Managed Networks.pdf

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