Joined-up care. delivering seamless care. A practical guide to making change happen

Transcription

1 CULTURE LEADERSHIP PATIENT CENTRED WORKFORCE MAKING IT HAPPEN Joined-up care delivering seamless care A practical guide to making change happen Authors: Carolyn Robertson Helen Baxter Mark Mugglestone Lynne Maher

2 Foreword Last year, my 80 year old father fell down in his garden and broke his hip. An ambulance arrived within a few minutes. My dad was whisked through Accident and Emergency and was quickly on the ward. My heart sank when I found out, particularly because his fall was at the weekend. I have worked on enough fractured neck of femur pathway redesign projects to know that, in these circumstances, there was a high likelihood that my dad might have to wait for a few days for his surgery. However, he was operated on within 24 hours and subsequently mobilised quickly and effectively. On the day that my father left hospital, what my mother described as a hit squad went round to their house before his discharge. They installed new banisters so he could get up the stairs and drilled new handles in his bathroom. They left him with a range of furniture including an armchair and a stool to sit on in the kitchen when he washed the dishes. The transition from hospital to community physiotherapist was seamless. He made a great recovery. The care was extraordinary because it was so ordinary. It wasn t special treatment; it was what everybody gets in North Bristol. It was DESIGNED to be reliable and effective. It wasn t obvious which organisation provided which part of the care, whether it was the ambulance service, community services, social services or community health services (I still haven t worked it all out!). But from the patient s point of view it didn t matter, it was just flawless and integrated with no delays or gaps. And care like this, which is joined-up and thought about in advance, is less likely to go wrong and saves precious NHS resources. I know that most people would be grateful if the NHS gave their parents care of this high standard. But for me there is something more profound. It was probably the first time that a member of my family got the overall standard of care that I aspire to in my role as an NHS improvement leader. The experience was like a living embodiment of the reason I do my job every day and what I would want for everyone who uses NHS services. That s why I m so pleased to have the opportunity to provide this forward to Joined-up care. Joined-up care doesn t require extra resources; it requires leadership will, some good ideas and a determined and disciplined approach to implementation. Most of all it requires us to create a sense of unity and common purpose amongst those who deliver the different elements of care so that we see ourselves as a united whole, delivering great care to patients. In an era of economic challenge joining-up care is one of the most effective strategies to improve productivity and reduce costs whilst improving quality. Helen Bevan Director of Service transformation, NHS institute 2

3 The evidence Putting patients at the centre of care to deliver world class outcomes. Joined-up care has long been advocated as a way of meeting the needs of patients with complex conditions. These patients are often in contact with different health and social care professionals and the quality of care they receive will be influenced by how well these professionals work together as well as the skills they bring to bear. Unfortunately, professional, financial and organisational barriers get in the way of joined up care, making it difficult to deliver the best possible outcomes to service users. The case for joined-up care is compelling. Evidence from both the United Kingdom and other countries shows the benefits of integrated approaches to service provision centred on the needs of patients (Curry and Ham, 2010). These approaches encompass fully integrated systems such as Kaiser Permanente and the Veterans Health Administration in the United States; integrated health and social care for older people, as exemplified in England by the work of the Torbay Care Trust; and care coordination for individual patients and carers, for example through the use of case management. International experience contains some important lessons for the NHS as further efforts are made to deliver joined-up care. First, organisational integration appears to be neither necessary nor always sufficient to improve outcomes for users. Much more important is clinical and service integration in which front line teams are enabled to work together to overcome fragmentation in care and provide services that are truly patient centred. Second, the benefits of integration hinge on action being taken at different levels. Improved care coordination for individual patients and carers needs to go hand in hand with work to integrate services for older people and other groups of patients with complex needs. In addition, umbrella organisational structures such as partnership boards have a part to play in bringing together senior leaders at a strategic level. Third, financial incentives must support joined-up care. This lesson is especially relevant in England in a context in which payment by results often puts barriers in the way of clinical teams working together to improve outcomes. Capitated budgets that offer incentives to promote prevention, rehabilitation and downward substitution of services are much more likely to produce the desired results than payment systems focused on organisational rather than system performance. Fourth, whatever approach is adopted, the impact of joined-up care depends critically on effective leadership, a collaborative culture that encourages team working, partnership between clinicians and managers, and a focus on responsibility for defined populations. Other important ingredients include accountability for performance, the use of guidelines to promote best practice and reduce unwarranted variations in care, and the adoption of information technology to facilitate integration and quality improvement. Integration in the absence of these ingredients is unlikely to fulfil its potential. These lessons need to be acted on in the NHS in the next phase of reform. There is no inherent contradiction between the desire to increase patient choice and provider competition on the one hand, and the imperative to deliver joined-up care on the other. Both policy makers and health and social care leaders should focus on how choice and competition can evolve between integrated systems with the aim of putting patients at the centre of care and delivering world class outcomes. Chris Ham Chief Executive of The Kingsfund 3

4 Introduction It is critical that in challenging economic times we work more closely with our partners between primary and secondary care, and between health and social care rather than retreating within our own organisational boundaries David Nicholson October 2010 Patients view the NHS as one service; they hope that services will work in a joined-up way to meet their individual needs. Healthcare professionals and patients know that the reality is often very different. When I left the hospital I thought I had all the information I needed. The nurse talked to me before I left and gave me a bundle of papers in case I forgot anything. When I got home and started to have a few problems I called the number given to me but they passed me on to someone else saying my care was nothing to do with them now. I spent about an hour and a half on the phone trying to get sorted out. It was so frustrating and I was made to feel a nuisance...when I finally got seen - 3 days later it was confirmed that I had an infection and that is why I was not feeling well. My treatment was delayed and all because the information I was given was wrong and I was in a void between different sections of the health system This quote is from a patient who had experienced difficulties in a particular healthcare area, but the reality is that this could be an example of any transition of care. As patients pass through boundaries within and between organisations on their healthcare journey, there is often duplication, inefficiency and waste that can create a poor experience. Working practices at these boundaries become disjointed and this also leads to frustration for staff. Focussing attention on how different services can work together for patients has a huge potential to both increase the quality of care provided as well as reducing waste and consequently the cost of providing that care. Joining services together to make a smooth system that is easily navigated is our challenge. The waste now is enormous, the duplication, errors and anguish we cause the prize is enormous David Fillingham, CEO, AQuA 4

5 This guide is aimed at organisations that are joining-up services, in particular those individuals who are tasked with making the changes happen. The approach that we have developed can be applied at a team or organisational level. It consists of: A brief guide outlining the principles and methods required for successful Joined-up care A How to website containing: Links to specific methods and practical tools that NHS Teams have used to develop and implement joined-up care locally A range of case study examples of joined-up care illustrating how teams have achieved this and the benefits that they have gained. A series of online seminars from national experts and case study sites We have found through our exploration of this subject that there are a whole range of really good examples of joined-up care. Everything was so clear, I always knew what was happening, I was involved in the discussion about my care, I knew what I needed to do and who was helping me at every stageit was easy and I felt confident There is is no single right way to undertake joined-up care and local circumstances must be considered to understand the most appropriate approach to take. However, there are a number of common principles that are critical for success. Within this guide we have outlined these principles and link them to a range of practical tools and approaches, used successfully by others, that will help you to work through a transformational change process within your own local context. The model in figure 1 (page 14) has been developed through our work with over 140 individuals and 24 NHS organisations, illustrating the core principles that need to be considered to successfully join-up care. Within this section we describe the model and share short extracts from some of the case studies we have gathered. The full version of each case study can be found on the web page at Joining-up care is not just about structures The NHS is a complex system that has developed over the last six decades, constantly evolving to meet both medical advances and changes in society. All complex systems are made up of structures, processes and patterns. Whenever we want to change, improve or transform a system, we need to consider each of these three aspects of the system. Traditionally in the NHS, when making organisational changes, we focus on changing the Structures within our system; for example we work on new boundaries, jobs, teams and targets. Clearly the structural changes are very important and excellent processes are required to make them work for those involved. However we often neglect the patterns that drive thinking and behaviour. By patterns we mean values, trust, how various groups communicate with one another for example. Often, reorganisations fail to achieve the fundamental change that is required because the underlying patterns in the system remain unchanged and unchallenged. 5

6 Figure 1 Principles for successful Joined-up care LEADERSHIP Measuring the improvement MAKING CULTURE PATIENT CENTRED IT HAPPEN Understanding the current state Developing and sharing the vision Prioritising the projects that will improve quality and productivity Implementation WORKFORCE We need to design services around communities and individuals rather than around our functions and organisations, which is how we deliver them now Sharon Beamish, CEO, George Eliot NHS Trust For example, if we spend time changing the organisational hierarchy but do not also focus on the new relationships, power base and ways to communicate, people within that organisation will usually just maintain what already exists. Often working with patterns of behaviour and considering relationships is thought of as being nebulous and difficult, but work on structures, processes and patterns are critical to achieving the transformational change that the NHS requires. The application of a Joinedup care approach needs to be addressed at every level of a system. Whilst needing effective senior leadership involvement, successful joined-up care usually comes from a pragmatic bottom up approach, so who we involve and how we involve them is critical to success. This most importantly includes the public, patients and the staff involved. 6

7 Patient centred Considering services from a user s point of view is a fantastic way of helping professionals involved to take a step back and see their services from a new perspective. This becomes a powerful motivator and driver for change, and can help to increase clinical engagement in the project. When staff hear how patients experience their services, the need for improvement is immediately apparent and the case for change becomes compelling. We make many assumptions that we know what it is like for patients and carers, but taking the step of actively finding out and involving them is critical when designing or changing a service. We heard time and again from individuals and organisations that we talked to, how powerfully the patient perspective was and how it motivated and inspired staff to transform their services: Nobody could argue about it because we were talking about making the patient journey better Telling the patients story has kept the focus in the right place and been a powerful motivator "It's the way patients feel at certain points of their care that leads us to the hard improvements" Key questions you should ask about patient involvement in designing your service These are some questions that you should ask yourself as you develop joined-up services. Visit our web site where you can look at case studies to see how others have tackled these challenges, and navigate to tools and programmes that might help you How do we know the experience of patients who use our services? Are we using patient information & experience as a baseline measurement for improvement? Are we developing the right approach, skills and tools to enable us to engage meaningfully with patients and the public? Do we gather and use patient stories as a powerful driver for improvement? Are we ensuring that patients and carers are actively involved in an ongoing and meaningful way in our programme? What are we doing to involve the public and staff in developing the vision? Are we debating some of the difficult options and decisions about service configurations with the public? Are we fully utilising the potential of technology to engage and involve service users? Case Study See how Barking and Dagenham PCT used the Experience Based Design Approach (EBD) to engage with patients and staff. Understanding how patients experience services, has shaped the pathway redesign, and they continue to be involved in the development and delivery of new services, the effect on clinicians hearing how patients experienced their services was astonishing and changed the conversations Do listen to your patients; always have them at the centre of your thinking, that s what makes the big, big difference 7

8 Leadership Great public service leadership, more than anything else, will be the key to improving quality and productivity David Nicholson 2010 Organisational leaders need to work together to develop a joint vision as well as articulating how it can happen in everyday practice. Creating a compelling narrative that effectively describes the vision and purpose of joining up services, making it real and relevant for all staff and stakeholders is a really important communication task. Leaders need to understand how the changes will impact on all staff and ensure that patterns which may manifest in cultural and behavioural challenges are considered alongside any structural, business and process components. It s also important to consider the role of all leaders within the organisation, leadership at every level: Organisation leaders have a disproportionately large effect on the cultures of organisations and systems (Maher 2009) and have a unique opportunity to influence effective joined-up care. To do this they need to work together to ensure the vision, purpose and narrative are in place, shared and delivered consistently. They need to openly and actively support other leaders who are responsible for developing the detail and making the changes happen. Clinical leaders are the custodians of clinical quality and need to contribute their wide ranging expertise to champion and achieve joined-up care. Both commissioners and providers also need to be able to articulate the vision from both a leadership and clinical perspective. Managers are perfectly placed to lead the changes at the front line, as operational experts they can make it happen. They act as role models turning the vision into reality, bringing teams along with them. Working on the detail of joining up care can be difficult and draining and these managers will need active support and encouragement from senior leadership teams. Don t forget middle managers, they have the power to block or enable, we need to help them to be drivers in this process Sara Radcliffe, Central Manchester Foundation Trust Case Study See how Trafford demonstrate the importance of leadership, both at executive level and clinical level. Visible and consistent leadership has driven forward the changes. Key questions you should ask about Leadership within your programme Are the senior leadership team visible and telling a powerful story about how joined-up care will improve services for patients, staff and the organisations involved? Do we have an effective and regular communications plan which will ensure all staff and patients involved can follow progress and contribute well. Who are our clinical leaders at all levels of the organisation? Do they have the skills and support to design and champion this work? Are we working closely with service managers so that they are helping to develop and implement the changes operationally? What support, skills and training might they need? Do we understand what our information is telling us about the quality of the services that we provide? How are we going to measure our improvements and outcomes of service redesign and who/where does this information need to go to achieve effective decision making 8

9 Culture Culture _ The presence of a positive and supportive organisational culture often goes hand in hand with high quality care and an enthusiastic workforce. When organisations and teams need to come together, understanding the similarities and differences between the organisational cultures, values and priorities can be a considerable challenge. This is often underestimated, but is essential to achieve joined-up care. Case Study See how Torbay Care Trust are developing Seamless care for patients with multiple co morbidities improving the interface between primary and secondary care, developing new models of working. They identify that changing the cultures and the underlying attitudes beliefs and subsequent behaviours is a big challenge. They are listening to individuals, bringing the groups together, to consider patient experience and to look at the qualitative data which is starting to break down the barriers, changing behaviours and allowing services to be delivered in new ways. keeping our reforms patient focussed became a driving force to change the culture, it broke down the barriers Helen Wilding, Torbay Care Trust Throughout any transition teams need to explicitly seek to understand the cultures and values of each of the organisations (or teams or departments) who need to work closely together in order to achieve joined-up care. There needs to be an openness and honesty to the discussions so that any real issues and challenges can be identified, understood and worked through. Building mutual trust is essential if care is to be successfully joined-up. We know of examples where clinicians have not trusted the judgement of other clinicians and have repeated a clinical assessment. This is not only unnecessary but it can be worrying for the patient and is a waste of time and money. We are also aware of examples where patient records are transposed from one form to another because of clinicians preferences, this type of practice is again wasteful but can also present a safety risk. Building trust is an important component in any process of joining-up care and failing to address it will mean that attempts to join-up care will not be successful. Recognising that people will feel uncomfortable and unsure during periods of change and spending time working with these feelings is beneficial. Key questions you should ask to make sure you are thinking about organisational cultures What are we doing to articulate the vision and values that we expect in the new joined-up services? Are we telling a compelling story about how the new services will improve the patient experience? Do we understand cultural behavioural patterns within our organisations and the implications that these might have on successful implementation of joined-up care? What help do teams need to change unhelpful patterns of behaviour, what can we do to help them to work together effectively? What can we do to build trust between individuals, teams and organisations? 9

10 Workforce Workforce The workforce is one of the most precious resources that we have. These are the people who have the potential, passion, skills and expertise to deliver high quality care which provides a great experience for patients and families. During any change there will not only be changes to the process of care but there will also be changes that impact on staff for example working hours, new skills, new relationships and even a new work base. Identifying these changes and engaging with staff early to look at the design of their roles will help to develop a shared understanding and ownership of the change. Even so, the anxiety that can be experienced by staff should not be underestimated. Uncertainty can lead to distress and result in negative or disruptive behaviours. The most important step is to engage with staff at all levels in all services that are affected, to listen, communicate and involve them in the changes. There is no doubt that staff can and do contribute greatly to change. For example, when developing new pathways of care, the really good innovative ideas will usually come from those staff who are working in those services. We need to create opportunities to engage staff as early as possible in the process, creating the right environment for clinicians and patients to work together to develop clinical pathways and new ways of providing services. Case Study See how George Elliott Hospital Trust skilled up large numbers of their staff to engage with the local population to find out what their needs were. They were, and continue to be involved in developing new ways of integrating and joining-up services, reducing waste and improving the experience of both patients and staff. We need to give permission given to our staff to work together in creative ways Linda Agnew, Ashton Leigh & Wigan PCT Integration has reduced the acute community divide. Has provided the opportunity for more productive dialogue between acute and community in relation to service re-design to ensure timely care close to home Linda Watson, North Tees & Hartlepool Key questions you should ask about the workforce issues of your programme Are the organisational leaders visible, available and directly engaged in conversations with the workforce about practical issues that concern staff? Are we involving staff early to develop and communicate the workforce plan effectively? Have we involved staff in developing the vision and setting the priorities - do we really understand the operational reality of what currently happens? Are we involving staff and patients in developing the new care pathways giving them the opportunity to come up with the innovative idea and solutions, develop new pathways and deliver the change through robust project management? Are all staff skilled in measurement for improvement techniques, are there robust governance arrangements in place to support them and drive the changes? What tools and skills do staff need to deliver transformational change? The deeper into the front line you go, the better the ideas Tim Evans, Bolton 10

11 Making it happen When starting to think about joiningup services, there is a key question that should be asked throughout the process: Are the changes that we are making going to transform services so that we improve the patient experience, remove the waste from the system, and develop cost efficient, high quality services for our population? The principles of patient centred, leadership, culture and workforce also need to be considered throughout any project. Making this all work in practice - How you start to join-up care is the most important thing. The reality of joining up services is always more complex and difficult than you think. Only by successfully carrying out the project and making it all work in practice will the benefits, for patients, staff and the NHS as a whole be realised. It is essential that you access existing expertise within the services and organisations that are involved in joining-up. If there are tools, techniques and approaches that people are familiar with, make the most of those. However we found that those responsible for joining up services wanted some additional guidance on what other tools to use and approaches that may be useful at different stages in joining-up care. To help you make the changes happen, we have linked programmes and tools to each process stage on our website, and also highlighted specific Case Studies so that you can learn from how others have approached some of the common challenges. Measuring the improvement MAKING IT HAPPEN Understanding the current state Developing and sharing the vision Prioritising the projects that will improve quality and productivity Implementation 11

12 Learning from others Case studies You told us that you wanted to hear about the experiences of organisations like yours who are going through the process of joining-up services. You wanted to know about the challenges they face, the way they have overcome these challenges and the lessons they ve learned along the way. We identified a broad spread of organisations that have either completed a significant part of the integration process or are deeply involved in the process right now. The challenges they face vary widely but many of the solutions are common to all. We have picked out these solutions and highlighted them as key themes or principles which are vital to the success of an integration project. These principles are listed below. We have used icons each time they occur in the case studies to make it easy for you to compare the different approaches used by individual organisations and the lessons they ve learned. We hope you find these case studies interesting, informative and inspirational. We would like to thank the organisations involved for sharing their experiences and insights so openly and honestly. Their insights are of huge benefit to us all and, ultimately, to our patients. Key themes _ Patient centred Clinical engagement Changing the culture Strong leadership Measurement Making it happen Joined-up care Case study summaries Read the full story by clicking onto the relevant organisation. Ashton, Leigh and Wigan Community Healthcare NHS Trust realised that its services were delivered in a way that suited professionals but not patients. Patients might see up to 10 separate professionals and be asked the same questions again and again. Read about how it changed community services to make them more patient-centred, by reorganising care pathways and removing professional boundaries. NHS Barking and Dagenham was concerned about the high level of hospital admissions among people with long-term conditions such as COPD. It set out to reduce demand for services by improving the management of long-term conditions and preventing hospital admissions. In three months, more than 300 stakeholders, 30 clinicians and 50 patients took part in a comprehensive programme of workshops and events. Patients have been given a voice in this process like never before. NHS Bolton is vertically integrating community services into the acute trust. Our case study explains the frank and open approach taken by Chief Executive, Tim Evans, who told staff he didn t have all the answers, and the big and small conversations taking place with staff across the two organisations. This up-front approach has won the support of staff and is helping the organisation to overcome some significant cultural differences in redesigning patient pathways. George Eliot Hospital Trust cares for Camp Hill in Nuneaton, one of the most deprived areas in England. It wanted to reduce dependence on hospital beds and move care closer to where people live, but knew from previous experience that local people would not readily access GP services. Working collaboratively with the local community and staff, this APMS (Alternative Provider of Medical Services) programme has developed a multiagency, one stop shop health centre which is radically changing the way local people access health and social care services. Northamptonshire Integrated Care Partnership brought together health, social care and third sector partners to improve the management of long-term conditions in the county. This Integrated Care Pilot has taken a system-wide approach to transforming community services and the results have been impressive. It has developed a new end of life service, a new community care of the elderly service and a case management system for people at high risk of emergency admission. 12

13 Learning from others Case studies Joined-up care Case study summaries Read the full story by clicking onto the relevant organisation. NHS North Tees & Hartlepool transferred the majority of its services to the Foundation Trust in November Since then, it has been integrating services along pathways of care to improve the patient experience, reduce duplication, and provide a seamless transition of care. Hartlepool s first integrated care centre became a reality in May 2010 with the opening of the 20m One Life facility and both staff and patients have welcomed the new integrated approach to community services. Oldham PCT is an excellent example of clinically-led service transformation. The region was among the highest spenders on musculoskeletal (MSK) services in the country. Commissioning for the entire MSK pathway, including orthopaedics, rheumatology and chronic pain, has now been transferred to the Commissioning for Oldham Group (COG) and Pennine Musculoskeletal Partnership (PMSKP), in conjunction with NHS Oldham. By April next year, these organisations will be responsible for the entire MSK budget. Torbay Care Trust has become a co-terminus authority, providing adult social care services alongside healthcare, in order to make real and meaningful improvements to the patient journey. The Chief Executive created a compelling story to demonstrated how patients experienced services that provided a compelling case for change. This patient centred approach is at the heart of all the organisations improvements driving the change. Trafford PCT is going for an ambitions, whole-system pathway redesign approach, which is being clinically-driven and led. The trust is still grappling with the day-to-day challenges of integration and trying to tackle the many issues that arise when striving for transformational change. Colleagues from Trafford talk openly and honestly about these challenges and share the lessons learned so far. 13

14 Appendix 1 Models for joined up care The initial focus for this work was the vertical integration model of Transforming Community Services (TCS). However, there are now a greater variety of models being developed, both in response to TCS and examples of system wide Joinedup care. Examples include Care Trusts integrating Health and social care services, developing a whole systems approach to integration of services in Integrated care partnership models as well as the various models evolving for TCS; Vertical integration, joining with acute or mental health Trusts, PCT provider organisations joining together to form Community Foundation Trusts and some Social Enterprise examples. (NB for further detail please see our Literature review). The evidence and our observations emphasised that there could and should not be one single model of integration. Instead models need to be developed in response to local context and local needs. Whilst this may sound admirable in theory, we recognise that there is a danger that in practice it makes the concept of Joined-up care feel less tangible. FIGURE 1: TYPOLOGIES OF INTEGRATED CARE Functional integration Organisational integration Integrated care to the patient Clinical integration Service integration To counteract this we have captured some case study examples to demonstrate how others have gone about it. None of the case study organisaitons would claim to have got everything right, but highlighting what worked and what didn t will be of great value to others undertaking a similar journey. Organisational integration, where organisations are brought together formally by mergers or through collectives and/or virtually through coordinated provider networks or via contracts between seperate organisations brockered by a purchaser. Functional integration, where non-clinical support and back-office functions are integrated, such as electronic patient records. Service integration, where different clinical services provided are integrated at an organisational level, such as through teams of multi-disciplinary professionals. Clinical integration, where care by professionals and providers to patients is integrated into a single or coherent process within an/or across professions, such as through use of shared guidelines and protocols. Normative integration, where an ethos of shared values and commitment to coordinating work enables trust and collaboration in delivering healthcare. Systemic integration, where there is coherence of rules and policies at all organisational levels. This is sometimes termed an integrated delivery system. Appendix 2 References and further reading Building integrated care; lessons from the UK and elsewhere, The NHS Confederation, (2006). A full version of the literature review is available at: egration_lit_review Department of Health (2010) Progress report: evaluation of the national integrated care pilots. Fulop, N et al (2002) Process and impact of mergers of NHS trusts: multicentre case study and management cost analysis BMJ;325: The Kings Fund & The Nuffield Trust, Where next for Integrated Care organisations in the English NHS (2010). The Kings fund & The Nuffield Trust, Removing the policy barriers to integration in England (2010). The Kings fund (2010) Improving health outcomes through clinical and service integration. 14

15 Acknowledgements We would like to thank the following for their contributions to this publication: David Fillingham - AQuA Paul Plesk Dr Steve Laitner - East of England SHA Sara Radcliffe - Central Manchester Foundation Trust Christine Lamb - NHS Manchester All of the staff from Central Manchester FT & NHS Manchester who participated in the Innovation Cycle workshops Colleagues from the NHS Institute of Innovation and Improvement. A Big thank you... A warm thank you to the many NHS staff, individuals and organisations who have generously given their time and shared their experiences to help us to create this Guide. Particular thanks to the NHS Organisations who have shared their stories and enabled us to develop Case Study examples of Joined-up care.